**9. Dental health issues for CSA survivors**

Dental health has gained increasing attention as a primary factor supporting overall health. Periodontal disease is now associated with upper respiratory illnesses such as pneumonia and cardiac conditions, even premature death (Eke, Thornton-Evans, Wei, Borgnakke, Dye, 2010). Given the importance of dental health in overall well-being, it is significant that by and large CSA Survivors have poor dental health, health seeking behaviors, and follow through with dental protocols (Hays & Stanley, 1996; Leeners, Stiller, Block, Gorres, Imthurn, Rath, 2009; Monahan & Forgash, 2000; Willumsen, 2004). As with physical health, dental health seeking behaviors can be defined as recognizing the necessity for dental care,

Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 145

Much of the same history gathering, rapport building, stabilization and collaboration is the same in cases of dental health for CSA survivors as with health issues. Educating both the CSA survivor and the dental and health practitioner regarding expectable reactions posttrauma and how to begin a purposeful, goal directed program toward health should be the primary goal. The following is a case example, from the second author, of earlier iatrogenic

Mrs. C , 35 years old, had avoided dental treatment since moving out of her family home when she married at age 25. As a small child she was sexually abused by her grandfather who lived with the family. He frequently orally raped her and threatened to beat her if she ever told anyone about it. This abuse went on until he was moved to a nursing home when she was 10 years old. The family dentist did not believe in any analgesia for pain when he had to fill cavities or pull any diseased teeth. She felt that the dentist was being "mean to her" like her grandfather. By her teens she had dissociative amnesia concerning the abuse by her grandfather. She disliked going to the dentist and was very consistent in her dental hygiene, hoping to avoid cavities. By the time she was 35, she had entered therapy with symptoms of PTSD . She reported that was having a toothache, and bleeding from her gums. She had begun to remember some fragments of the sexual abuse and the harsh dental treatment from childhood. Her therapist taught her relaxation techniques, to alleviate some anxiety. She spoke with the dentist her husband saw who assured her he would do everything he could to make the experience as painless as possible. Her therapist coached her to tell him some general information about her abuse and early dental trauma. The therapist and dentist telephone conferenced and discussed some strategies to help the

The dentist was also well versed in relaxation techniques and was able to talk the patient through some exercises. He provided her with headphones and soft music of her choice. In her next therapy session, the therapist and patient reviewed what had gone well and planned for any additional skills the patient felt she needed. They both felt that the patient felt stabilized and safe enough to begin trauma work on the sexual abuse by her grandfather. The therapist was trained in a phased model of trauma treatment to work through and resolve the trauma. The patient also, with the help of the current positive dental experience, resolved the earlier dental trauma to the point that she was able to plan for long term dental and periodontal treatment. However, there were severe problems, notably, damage from clenching, grinding and teeth broken off at the gum line and bone loss from periodontal disease. This was the legacy of years of avoidance of dental care and

As part of psychotherapy with this population, reviewing how trauma has impacted their health seeking behaviors and, ultimately their health, is imperative. As mentioned, CSA survivors may not have viewed their trauma histories as having any bearing on their conduct with their health, and/or believing that they do not deserve good health outcomes. Additionally, they may believe that they should not be assertive with health care professionals, have the right to ask questions, or get a second opinion. CSA survivors may demonstrate a lack of cooperation, poor decision making, or even the inability to retain important health information, and it is important for the health care professional to

trauma and collaboration between the dentist and the mental health practitioner.

patient during and after the session in the dental chair.

**Techniques for being a good health care consumer** 

the dental /childhood trauma.

making and keeping appointments with the dentist, follow-through with dental advice and hygiene, e.g., brushing teeth, flossing daily, annual visits, and finally, follow through with necessary procedures.

CSA Survivors are resistant to dental treatment for much of the same reasons that they have difficulty with health issues. Feelings of un-deservedness, low self-esteem and self-worth, poor parental modeling and instruction of good dental care, and denial of dental health care needs are the primary issues that underscore the CSA Survivors lack of dental care.

Several other issues factor into the CSA Survivors lack of dental care. While the general population may experience reluctance and even phobia when it comes to dental care, the survivor may have experienced oral rape and this compounds her reluctance to seek dental care. Additionally, because of her overall fear and trepidation about the dental experience she may have experienced trauma in the dental chair, with a dentist unfamiliar with trauma victims. Lack of knowledge, experience, and patience in dealing with this type of situation, can cause iatrogenic trauma. Table 2 lists some of these issues.

Poor Dental Health Seeking:


Untreated Dental Pain, Periodontal Problems, TMJ, Malocclusions

Difficulty Sitting and Reclining in the Dental Chair

Difficulty Communicating dental fear or abuse history

This table was compiled using data from AMA, *Diagnostic & Treatment Guidelines on Mental Health Effects of Family Violence*, Chicago, IL.: AMA, 1995; Hays, K.F. & Stanley, S.F. (1996). The Impact of Childhood Sexual Abuse on Women's Dental Experiences. *Journal of Child Sexual Abuse*, 5, 65-74; Monahan & Forgash, (2000). Enhancing the Health Care Experiences of Adult Female Survivors of Childhood Sexual Abuse, *Women & Health*, 30(4), 27-41; Randomsky, N., *Lost Voices, Women, Chronic Pain and Abuse*. New York, NY: Harrington Park Press, 1995; Sidran Institute, Dental Tips for Sexual Abuse Survivors

Table 2. Common Dental Difficulties Reported By CSA Survivors

Several studies indicate that respondents have experienced at least one painful dental encounter (Klepac et al, 1980; Vassend, 1993) and the general population still approaches dental experiences with some level of dental fear. Childhood sexual abuse survivors may experience a *pronounced* level of fear emanating from oral rape and therefore it is important to understand that sexual assault that involved the mouth may result in CSA survivors' reluctance to address their dental health needs and avoid visits to dental health practitioners. (Stalker, Russell, Teram, Schachter, 2005; Teram; Leeners, Stiller, Block, Görres, Imthurn, Rath, 2007) Other reasons may include: viewing the experience as intrusive, experiencing loss of control coupled with a sense of powerlessness, and, most importantly, procedures that may be symbolic and trigger painful memories of childhood abuse (Monahan & Forgash, 2000; 2011).

making and keeping appointments with the dentist, follow-through with dental advice and hygiene, e.g., brushing teeth, flossing daily, annual visits, and finally, follow through with

CSA Survivors are resistant to dental treatment for much of the same reasons that they have difficulty with health issues. Feelings of un-deservedness, low self-esteem and self-worth, poor parental modeling and instruction of good dental care, and denial of dental health care

Several other issues factor into the CSA Survivors lack of dental care. While the general population may experience reluctance and even phobia when it comes to dental care, the survivor may have experienced oral rape and this compounds her reluctance to seek dental care. Additionally, because of her overall fear and trepidation about the dental experience she may have experienced trauma in the dental chair, with a dentist unfamiliar with trauma victims. Lack of knowledge, experience, and patience in dealing with this type of situation,

needs are the primary issues that underscore the CSA Survivors lack of dental care.

can cause iatrogenic trauma. Table 2 lists some of these issues.

Lack of or inconsistency in dental hygiene

Difficulty Sitting and Reclining in the Dental Chair

Difficulty Communicating dental fear or abuse history

Table 2. Common Dental Difficulties Reported By CSA Survivors

 Few to no dental check-ups in childhood or adulthood Untreated Dental Pain, Periodontal Problems, TMJ, Malocclusions

This table was compiled using data from AMA, *Diagnostic & Treatment Guidelines on Mental Health Effects of Family Violence*, Chicago, IL.: AMA, 1995; Hays, K.F. & Stanley, S.F. (1996). The Impact of Childhood Sexual Abuse on Women's Dental Experiences. *Journal of Child Sexual Abuse*, 5, 65-74; Monahan & Forgash, (2000). Enhancing the Health Care Experiences of Adult Female Survivors of Childhood Sexual Abuse, *Women & Health*, 30(4), 27-41; Randomsky, N., *Lost Voices, Women, Chronic Pain and Abuse*. New York, NY: Harrington Park Press, 1995; Sidran Institute, Dental Tips for Sexual

Several studies indicate that respondents have experienced at least one painful dental encounter (Klepac et al, 1980; Vassend, 1993) and the general population still approaches dental experiences with some level of dental fear. Childhood sexual abuse survivors may experience a *pronounced* level of fear emanating from oral rape and therefore it is important to understand that sexual assault that involved the mouth may result in CSA survivors' reluctance to address their dental health needs and avoid visits to dental health practitioners. (Stalker, Russell, Teram, Schachter, 2005; Teram; Leeners, Stiller, Block, Görres, Imthurn, Rath, 2007) Other reasons may include: viewing the experience as intrusive, experiencing loss of control coupled with a sense of powerlessness, and, most importantly, procedures that may be symbolic and trigger painful memories of childhood abuse

Poor Dental Health Seeking:

Abuse Survivors

(Monahan & Forgash, 2000; 2011).

necessary procedures.

Much of the same history gathering, rapport building, stabilization and collaboration is the same in cases of dental health for CSA survivors as with health issues. Educating both the CSA survivor and the dental and health practitioner regarding expectable reactions posttrauma and how to begin a purposeful, goal directed program toward health should be the primary goal. The following is a case example, from the second author, of earlier iatrogenic trauma and collaboration between the dentist and the mental health practitioner.

Mrs. C , 35 years old, had avoided dental treatment since moving out of her family home when she married at age 25. As a small child she was sexually abused by her grandfather who lived with the family. He frequently orally raped her and threatened to beat her if she ever told anyone about it. This abuse went on until he was moved to a nursing home when she was 10 years old. The family dentist did not believe in any analgesia for pain when he had to fill cavities or pull any diseased teeth. She felt that the dentist was being "mean to her" like her grandfather. By her teens she had dissociative amnesia concerning the abuse by her grandfather. She disliked going to the dentist and was very consistent in her dental hygiene, hoping to avoid cavities. By the time she was 35, she had entered therapy with symptoms of PTSD . She reported that was having a toothache, and bleeding from her gums. She had begun to remember some fragments of the sexual abuse and the harsh dental treatment from childhood. Her therapist taught her relaxation techniques, to alleviate some anxiety. She spoke with the dentist her husband saw who assured her he would do everything he could to make the experience as painless as possible. Her therapist coached her to tell him some general information about her abuse and early dental trauma. The therapist and dentist telephone conferenced and discussed some strategies to help the patient during and after the session in the dental chair.

The dentist was also well versed in relaxation techniques and was able to talk the patient through some exercises. He provided her with headphones and soft music of her choice. In her next therapy session, the therapist and patient reviewed what had gone well and planned for any additional skills the patient felt she needed. They both felt that the patient felt stabilized and safe enough to begin trauma work on the sexual abuse by her grandfather. The therapist was trained in a phased model of trauma treatment to work through and resolve the trauma. The patient also, with the help of the current positive dental experience, resolved the earlier dental trauma to the point that she was able to plan for long term dental and periodontal treatment. However, there were severe problems, notably, damage from clenching, grinding and teeth broken off at the gum line and bone loss from periodontal disease. This was the legacy of years of avoidance of dental care and the dental /childhood trauma.

#### **Techniques for being a good health care consumer**

As part of psychotherapy with this population, reviewing how trauma has impacted their health seeking behaviors and, ultimately their health, is imperative. As mentioned, CSA survivors may not have viewed their trauma histories as having any bearing on their conduct with their health, and/or believing that they do not deserve good health outcomes. Additionally, they may believe that they should not be assertive with health care professionals, have the right to ask questions, or get a second opinion. CSA survivors may demonstrate a lack of cooperation, poor decision making, or even the inability to retain important health information, and it is important for the health care professional to

Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 147

symptoms as necessary preparation for phase two: trauma treatment. In this phase collaboration with existing support networks or developing them begins (Ford et al, 2005).

Once safety and stability have been well established, identifying, exploring, and processing the traumatic experiences can take place. Additionally, emotions such as shame, guilt, and helplessness need to be understood and processed. As acceptance of past actions takes place, and responsibility for abuse is correctly assigned to the perpetrator, internal conflicts can be addressed and resolved. The patient can slowly begin to give up the victim role, practice new more assertive behaviors and beliefs, and begin to 'deserve' good health. Additionally, the patient begins to review and predict where in this process they may have difficulty, and apply some of the basic principles of "relapse" prevention, e.g, falling back to old behaviors

In this phase, patients work to regain control of their lives and achieve healthy functioning and efficacy in life domains. They work on gaining positive self worth and identity and a sense of empowerment. The patient often reports seeing old events and relationships from more of an adult perspective. Additionally, they express feelings of competence and can

It should be noted that in all phases of this work, but particularly in the beginning, the patient may test the mental health professional as part of reenactment of earlier rejection and betrayal by family members, or insecure attachment styles. The mental health practitioner may find that attunement through non-verbal, affective, and bodily communication takes on heightened importance (Ford et al, 2005; Fosha, 2000; Ogden, &

**Collaboration between the healthcare professional and the mental health practitioner** 

Collaboration or a team approach provides a more comprehensive and successful outcome for the CSA survivor in accessing and following through with health care needs. Ethical practice always demands that consent be obtained to contact another treating professional. But more importantly, once a team approach is decided upon, obtaining consent from the CSA survivor to contact another health professional, often provides her with a sense of

The mental health professional can act as the patient's advocate and assist in explaining background, symptoms, and specific needs. The mental health practitioner may also explain some of the abuse issues and problems stemming from the trauma. In situations where flashbacks and dissociation are prominent, the mental health practitioner can explain these reactions and assist the health care professional in what to do. The mental health practitioner can let the health professional know the patient's stage of treatment and how that will impact medical treatment. The following case example describes collaboration between the mental health practitioner, the medical specialist, and the

**11. Phase II** 

**12. Phase III** 

control.

patient.

that negated his/her rights to good health.

attend to their healthcare needs as an adult.

Minton, 2000) during all the phases of therapy.

understand that this lack of health assertive behavior emanates from fear, confusion, dissociation, poor health care modeling, and an over all sense that he/she does not deserve attention or good health care. Additionally, the psychotherapist can share and discuss information and how-to techniques on becoming a healthcare consumer with the patient. Many organizations produce informational brochures and flyers on health consumerism for sexual abuse survivors.

Psycho-education regarding health care needs and developing assertive behavior with health care professionals can improve the health outcomes for CSA survivors and is a necessary part of psychotherapy with the CSA survivor.

#### **Teaching the CSA survivor how to modulate stress and improve health outcomes through psychotherapy**

Psychotherapy with CSA survivors is generally constructed around a three-stage approach that begins with establishing safety, stabilization and emotional regulation (Ford, Courtois, Steele, van der Hart, Nijenhuis, 2005). While there are a variety of treatment models addressing the issues of trauma available today, most of these treatments are phase-oriented and focus initially on establishing safety for the patient and the therapeutic relationship as the foundation of the work in which processing trauma occurs. The therapeutic relationship becomes the "container" – the holder of painful memories, thoughts, and issues related to the traumatic event. More importantly, the mental health practitioner becomes the model for containment through support that is consistent, boundaries that are well established, and empathic interest in the patient (Ford et al, 2005). The patient will explore and reprocess the traumatic events and finally, achieve mastery and resolution of life issues.

The mental health practitioner should be a warm, genuine individual who can provide an empathic stance, thus formulating the foundation for a therapeutic alliance. It is important for the therapist to retain this empathic demeanor as well as a calm façade when hearing distressing histories from the CSA survivor, generally not a minor feat to accomplish. Sessions should be consistent and the mental health practitioner should provide the CSA survivor with what has been called, "a corrective emotional experience" (Alexander & French, 1946) throughout the course of therapy.
