**3. Impact of CSA on alexithymia, dissociation, and self**

### **3.1 Impact of CSA on alexithymia**

76 Sexual Abuse – Breaking the Silence

not an issue of importance. There were no doubts on what had happened to them, because quite often there was a whole regiment of witnesses. However doubts existed on whether soldiers were really ill as they displayed a wide array of behavior that nowadays would be classified as conversion hysteria. Since Horowitz's (1976) introduction of the Theory of Stress Response Syndromes there has been a growing interest in the effects of exposure to traumatic events, and the systematic investigation of complaints reported by male survivors of war resulted in the description of Post Traumatic Stress Disorder (PTSD). However it took much longer before reports of CSA in women were taken seriously. Already from the end of the 19th century reports on female sexual abuse were considered to be false sexual allegations ('sexuelle Falschanschuldigungen' in German, see Birnbaum, 1915) and in France it was called the phenomenon of the 'accusatrices hystériques' (see Garnier, 1903). This tradition was kept alive when Psychoanalysis dominated the academic scene, as accounts of sexual abuse were simply treated as 'Oedipal Fantasies'. Hence, the term 'pseudologia phantastica' is firmly rooted in the history of CSA. Only quite recently, during the second feministic wave in the last two decades of the 20ieth century it was acknowledged by academic psychology that CSA really occurs and that the effects can be traumatic enough to meet the criteria of PTSD (see Finkelhor & Browne, 1985; Albach & Everaerd, 1992; Albach, 1993; Zeitlin et al., 1993). However, the battle had not been won yet. In particular women with repressed memories of sexual abuse (those who experienced episodes of inability to recall the event) had a long history of being treated with great suspicion (Albach et al., 1996). The last revival of this skeptic tradition (the abuse did not really happen) evolved after 1990 and was based on the idea of false or implanted memories created under hypnosis in psychotherapy (Ceci & Loftus, 1994; Loftus, 1993, 1997). The foregoing on credibility illustrates well that war victims and CSA women have in common that both were accused of pretending or lying, however on different grounds. Soldiers were accused of lying about their illness; by malingering they tried to avoid being sent back to the deadly frontlines, while CSA women were accused of lying about what had happened to them, e.g. about the sexual abuse as an excuse or explanation for their current miserable psychological state (Crombach &

Until recently studies on CSA were almost uniquely based on women. Empirical studies on the impact of CSA in male victims were beyond the scope of the feministic perspective. However the numerous recent reports of male CSA victims within the Roman Catholic Church in the media inevitably had to lead to a shift of focus in this female-only approach. Comparisons between female and male victims are a logical consequence. It is striking that in all female cases fantasy-proneness or high suggestibility is used as a personality trait causing women to report such lies or false memories, while in the recent cases of male sexual abuse, in the media hardly any doubts on the credibility of the reports of the male victims has been expressed. It might be that under enormous political pressure from the media, the already badly wounded Catholic Church had no other way-out than to stand in a white sheet, and the priests, some of whom are still alive, lost their status of inviolability and as a consequence had to confess their misconduct. Although it cannot be denied that in some cases women do lie about or simulate sexual abuse (see the literature on false memories, for instance Yapko, 1994), as by the way happens with many other events in court, it remains remarkable that *even the second feministic wave has not been robust enough to prevent women from being accused of hysteria, making up stories or lying about sexual abuse, while the credibility of men reporting being molested by* 

Merkelbach, 1996).

Alexithymia has been introduced by Sifneos and literally means *'wordless affect'*, indicating the incapacity to recognize and express the emotional experience in verbal forms. Sifneos (1973) came up with this term after observing that a great amount of patients suffering from psychosomatic complaints were not able to verbally express and describe their affective experience and also distinguish it from bodily sensations; such difficulty constituted only a part of a wider cluster of cognitive and affective characteristics also including restricted imagination characterized by a marked paucity of fantasy and a literal, utilitarian cognitive style that is externally oriented. This cluster of characteristics constitutes a major obstacle in the process of treatment and contributes to the failure of response to therapy (Sifneos, 1975).

Krystal (1988) was probably the first to emphasize that alexithymia is one of the sequelae of traumatic experiences. From research data evidence exists for the idea that psycho-traumata can indeed induce alexithymia (Hyer et al., 1990; Thomas et al., 1992; Berenbaum & James, 1994; Zlotnick, et al., 2001; Frewen et al., 2008). Victims of both rape (Zeitlin et al., 1993) and CSA (Albach & Everaerd, 1992; Berenbaum, 1996; Cloitre et al., 1997; Moormann et al, 1997; Sher & Twaite, 1999; Bermond et al., 2008) are known to suffer from alexithymia. Milder forms of CSA are not always associated with alexithymia (Paivio & McCulloch, 2004; Kooiman et al., 2004; Modestine, Furrer, & Malti, 2005).

#### **3.2 Impact of CSA on dissociation**

Pierre Janet (1889) was the first to describe the concept of dissociation as a result of his extensive work with hysteric patients. He referred to dissociation as a process involving the breaking down of those structures of the mind that are interconnected within a single stream of consciousness. More specifically, the mind is constructed by separate compartments constituting from emotions, cognitions and actions; however as a consequence of trauma, stress or weakness the breakdown of this stream of consciousness may occur as a result of the splitting of one of those structures from the rest. Such alternations then in those structures inhibit the normal integration of information to the components that are involved and induce alternations in memory and identity, promoting in such way the development of different kinds of dissociative disorders, depending on the severity of the symptoms (Putnam, 1993).

Dissociation, one of the adverse effects of CSA (Chu & Dill, 1990; Ensink, 1992; Kirby et al., 1999; Kisiel & Lyons, 2001 ), is often studied together with alexithymia, and both constructs

Gender Differences in the Impact of Child Sexual Abuse on Alexithymia, Dissociation and Self 79

Gender differences in alexithymia, dissociation, and self have been published in populations other than CSA. The general picture reveals higher alexithymia scores for men on the BVAQ (Vorst & Bermond, 2001). However, reports using the TAS, failed to demonstrate such gender differences in alexithymia (Parker, Taylor & Bagby, 1989). While, in general men were found to be more alexithymic, women tended to be more vulnerable to dissociation (Coons, 1996; Ross, 1996). Many researchers though reported surpassing scores for males on the frequency of dissociative disorders in various populations including children, adolescents, criminal offenders and forensic patients are reported as well (Kluft, 1996; Putnam et al., 1996). These inconclusive findings can be attributed to methodological problems, such as comparing outcomes from classification systems with outcomes from questionnaires, different populations, and different instruments. For self gender outcomes are even more confusing because researchers have a tendency to make a distinction between an interdependent and an independent self-construal. The social, institutional, and cultural environment of the United States for instance promotes development of independence and autonomy in men and interdependence and relatedness in women (Bakan, 1966; Maccoby, 1990; Markus & Oyserman, 1989). Therefore the outcome of the comparison is dependent upon the self-construal chosen which hampers the making of absolute statements on gender

The comparatively few studies that did investigate both male and female CSA victims seem to indicate that the variety of maladaptive psychological behaviours and psychiatric disorders associated with CSA are expressed differently in boys and girls (Walker et al., 2004). In general, girls manifest a tendency to *internalizing* behaviours (Butler & Nolen-Hoeksema, 1994). Boys on the other hand have been found to display a coping style in response to CSA characterized by more *externalizing* behaviours (Garnefski & Arends, 1998; Kuhn et al., 1998). The different expressions of the impact of CSA on gender may be partly explained by the influence of CSA on gender identity. Male victims seem to become more commonly confused about their sexual identity and orientation in heterosexual relationships (Tzeng & Schwarzin, 1990). Such confusion stems from any type of perceived responsiveness to the incident taking place from the same sex abuser and may lead to the assumption that the masculinity of the victim has been compromised (Moody, 1999). In such cases boys may be more prone to acting out aggression and engaging in delinquent activities in an effort to compensate for and re-establish their perceived loss of masculinity (Rogers & Terry, 1984). Girls on the other hand tend to display a more damaged self esteem and self blame, not only because of their tendency to ruminate, but also because in many cases they are often held responsible for the abuse by suggesting that girls seduced and encouraged the perpetrator (Carmen et al., 1984; Herman, 1981; Kohn 1987), with shame and guilt feelings as a consequence. Additionally, fear and distress enhance a maladaptive vulnerability that

b. High dissociation scores, indicative of Dissociative Identity Disorder (DID).

**3.4 Hypotheses** 

c. A negative self.

differences.

Victims of CSA will display:

a. A high prevalence of alexithymia.

**4. Explorative part: Gender differences** 

are considered to contribute to the enhancement of emotional disengagement from the traumatic event (Zlotnick et al., 1996; Irwin & Melbin-Helberg, 1997; Grabe, et al., 2000; Elzinga, et al. (2002); Moormann et al., 2004).

#### **3.3 Impact of CSA on self**

The first psychologist to develop a theory of self was William James (1890). According to his theory self consists of four integrated parts: the "spiritual self" (what we most truly seem to be), the "social self" (individuals and groups about whose opinion we care), the "material self" (material possession we see as part of us) and the "bodily self" (body image). These four selves combine to constitute each person's view of himself and his self-concept. Furthermore, James developed his theory as to the position a person holds in the world, which determines his self-esteem depending on his success or failure. Our perceptions of where we see ourselves standing in relation to others whose skills and abilities are similar to our own determine our inner feeling of self-worth.

Regarding self and CSA, Janoff-Bulman and Frieze (1983) argue that the trauma of victimization activates negative self-images. Victims see themselves as weak, helpless, needy, frightened and out of control. They are also apt to experience a sense of deviance. Therefore, effective coping with victimization requires not only coming to terms with a world in which bad experiences happen to one-self, but also restoring a damaged selfimage. Low self-regard, commonly found among victims of repeated sexual abuse is emphasized by Russell (1986) as follows (p. 190):

*"Women who place or find themselves in risky situations in the predatory world in which we live are quite likely to be raped. This does not, of course, mean they want to be raped, or that they don't mind it. It means that their self-esteem may be so damaged that they don't feel they deserve their own loving self-protection. This, in turn, can result in repeated victimizations, each one of which can undermine a women's self-esteem still further".* 

A survey done by Russell and co-workers (1986) shows that re-victimization is most of the time neither a one-time experience nor a rare occurrence, but more often extremely common. The kind of behavior displayed by the victim might be the reason why revictimization in children happens so often. Clinical accounts indicate that sexual offenders who don't know about a child's previous victimization may be experts at picking up cues of vulnerability, such as low self-image or a strong but unsatisfied need for affection and attention. Finkelhor and Browne (1985) have developed a theoretical model for analyzing child sexual abuse in terms of four trauma-causing factors: traumatic sexualization (i.e., a child's sexuality is shaped in a developmentally inappropriate and interpersonally dysfunctional fashion as a result of sexual abuse), stigmatization (i.e., negative connotations - e.g., badness, shame, and guilt, that are communicated to the child around the experiences and that then become incorporated into the child's self-image), betrayal (i.e., children discover that someone on whom they were vitally dependent has caused them harm), and powerlessness (i.e. the child's will, desires, and sense of efficacy are continually contravened). Finkelhor and Browne refer to these factors as *traumagenic dynamics*, and suggest that these factors alter children's cognitive and emotional orientation to the world, and create trauma by distorting children's self-concept, worldview, and affective capacities.

#### **3.4 Hypotheses**

78 Sexual Abuse – Breaking the Silence

are considered to contribute to the enhancement of emotional disengagement from the traumatic event (Zlotnick et al., 1996; Irwin & Melbin-Helberg, 1997; Grabe, et al., 2000;

The first psychologist to develop a theory of self was William James (1890). According to his theory self consists of four integrated parts: the "spiritual self" (what we most truly seem to be), the "social self" (individuals and groups about whose opinion we care), the "material self" (material possession we see as part of us) and the "bodily self" (body image). These four selves combine to constitute each person's view of himself and his self-concept. Furthermore, James developed his theory as to the position a person holds in the world, which determines his self-esteem depending on his success or failure. Our perceptions of where we see ourselves standing in relation to others whose skills and abilities are similar to

Regarding self and CSA, Janoff-Bulman and Frieze (1983) argue that the trauma of victimization activates negative self-images. Victims see themselves as weak, helpless, needy, frightened and out of control. They are also apt to experience a sense of deviance. Therefore, effective coping with victimization requires not only coming to terms with a world in which bad experiences happen to one-self, but also restoring a damaged selfimage. Low self-regard, commonly found among victims of repeated sexual abuse is

*"Women who place or find themselves in risky situations in the predatory world in which we live are quite likely to be raped. This does not, of course, mean they want to be raped, or that they don't mind it. It means that their self-esteem may be so damaged that they don't feel they deserve their own loving self-protection. This, in turn, can result in repeated victimizations, each one of which can* 

A survey done by Russell and co-workers (1986) shows that re-victimization is most of the time neither a one-time experience nor a rare occurrence, but more often extremely common. The kind of behavior displayed by the victim might be the reason why revictimization in children happens so often. Clinical accounts indicate that sexual offenders who don't know about a child's previous victimization may be experts at picking up cues of vulnerability, such as low self-image or a strong but unsatisfied need for affection and attention. Finkelhor and Browne (1985) have developed a theoretical model for analyzing child sexual abuse in terms of four trauma-causing factors: traumatic sexualization (i.e., a child's sexuality is shaped in a developmentally inappropriate and interpersonally dysfunctional fashion as a result of sexual abuse), stigmatization (i.e., negative connotations - e.g., badness, shame, and guilt, that are communicated to the child around the experiences and that then become incorporated into the child's self-image), betrayal (i.e., children discover that someone on whom they were vitally dependent has caused them harm), and powerlessness (i.e. the child's will, desires, and sense of efficacy are continually contravened). Finkelhor and Browne refer to these factors as *traumagenic dynamics*, and suggest that these factors alter children's cognitive and emotional orientation to the world, and create trauma by distorting children's self-concept, world-

Elzinga, et al. (2002); Moormann et al., 2004).

our own determine our inner feeling of self-worth.

emphasized by Russell (1986) as follows (p. 190):

*undermine a women's self-esteem still further".* 

view, and affective capacities.

**3.3 Impact of CSA on self** 

Victims of CSA will display:

