**Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes**

Kathleen Monahan1 and Carol Forgash2

*Stony Brook University, Stony Brook, N. Y., Private Practice, Smithtown, N.Y., USA* 

#### **1. Introduction**

136 Sexual Abuse – Breaking the Silence

[17] Makoroff K, Brauley J, Brandner A, Myers P, Shapiro R. Genital examinations for

[18] Balençon M, Roussey M. Examen et conduite à tenir chez le jeune enfant victime

[19] Palusci VJ, Cyrus TA. Reaction to video colposcopy in the assesment of child sexual

[20] Adams JA, Kaplan RA, Starling SP, Mehta NH, Finkel MA, Botash AS, Kellog ND,

[21] Bernard D, Peters M, Makoroff K. The evaluation of suspected pediatric sexual abuse.

[22] Myhre AK, Mykelstad K, Adams JA. Changes in genital anatomy and microbiology in

[23] Adams JA. Medical evaluation of suspected child sexual abuse. APSAC Advisor

[24] Benjamins LJ. Genital trauma in pediatric and adolescent females. J Pediatr Adolesc

[25] Goodyear-Smith F. What is the evidence for non-sexual transmission of gonorrhea in

[26] La Voix de L'Enfant: Permanences et unités d'accueil médico-légales pour les enfants victimes de Violences Sexuelles France 2002 www.lavoixdelenfant.org [27] Edinburgh L, Saewy E, Levitt C. Caring for young adolescent sexual abuse victims in a hospital-based children's advocacy center. Child Abuse & Neglect 2008;32:119–26 [28] Smith DW, Witte TH, Fricker-Elhai AE. Service outcomes in physical and sexual abuse

[29] Tishelman AC, Meyer SK, Haney P, McLeod SK. The clinical-forensic dichotomy in

[30] Bouchard EM, Tourigny M, Joly J, Hébert M, Cyr M. Les conséquences à long terme de

d'épidémiologie et de santé publique 2008;56:333–44

d'abus sexuels. J Pédiatr Puericulture 2000;13:36-42

abused. J Pediatr Adolesce Gynecol 2007;20:163–72

abuse. Child Abuse & Neglect 2001;25:1535–46

Clin Ped Emerg Med 2006;7:161–9

Gynecol 2010;23:77–85

Gynecol 2009;22:129–33

Maltreat. 2006;11:354–60

2010;19:590–608.

Legal Medicine 2007;14:489–502

2010;22:2–7

2002;26:1235–42

alleged sexual abuse of prepubertal girls: finding by pediatric emergency medicine physicians compared with child abuse trained physicians. Child Abuse & Neglect

Shapiro SA. Guidelines for medical care of children who may have been sexually

girls between age 6 and age 12 years: a longitudinal study. J Pediatr Adolesc

children after the neonatal period? A systematic review. Journal of Forensic and

cases: a comparison of child advocacy center-based and standard services. Child

sexual abuse evaluations: moving toward an integrative model. J Child Sex Abus.

la violence sexuelle, physique et psychologique vécue dans l'enfance. Revue

This chapter addresses the negative health outcomes for adult childhood sexual abuse (CSA) survivors. It is now well established that CSA survivors have a myriad of long- term physical health related disorders and disease processes (Boscarino, 2004; Irish, Kobayashi, & Delahanty, 2010; Monahan & Forgash, 2000) mental health difficulties, (Briere & Scott, 2006; Briere & Weathers, 2005; Brown, 2009) and dental health issues (Teram; Leeners, Stiller, Block, Görres, Imthurn, Rath, 2007). Many of these individuals will exhibit health risk behaviors as well (Felitti, Anda, Nordenberg et al, 1998; Owens & Chard, 2001; Chartier, Walker, Naimark, 2008; Liebshutz et al., 2000; Meade, Kershaw, Hansen, Sikkema, 2009). Additionally, oral and dental health has been recognized as a strong predictor of physical health problems. Recently, the dental health of CSA survivors has been an area of investigation.

The trauma field has long recognized the association between childhood trauma, PTSD symptomatology and health issues (Schnurr, 1996). One of the most recognized studies to date is the Adverse Childhood Experiences (ACE) study which gathered information from 17, 337 adults 50 years and older (Felitti, Anda, Nordenberg et al, 1998). Information on current health status and childhood adverse experiences such as vitriolic divorce, abuse and neglect, a parent dying, and witnessing one's mother being beaten, were collected. The study found that 30.1% of the respondents reported being physically abused, 19.9% reported sexual abuse, and 11% reported being emotionally abused (Felitti, Anda, Nordenberg, et al, 1998). Moreover, the study found that childhood stressors are strongly related to the development and prevalence of risks factors for disease and health and social well-being throughout the life span (Felitti, Anda, Nordenberg et al, 1998). The authors state,

The ACE study reveals a powerful relationship between our emotional experiences as children and our physical and mental health as adults, as well as the major cause of adult mortality in the United States. It documents the conversion of traumatic emotional experiences in childhood into organic disease later in life (p. 245).

In addition, the more adverse experiences one reported, the more likely one was to develop severe, life-threatening health outcomes such as heart disease, skeletal fractures, stroke, diabetes, and cancer (Filetti, Anda, Nordenberg et al, 1998; van der Kolk, 2005). The ACE study points out that childhood abuse has life-long impact on the health and well being of the victim. Filetti (2001) questions, "How does one perform reverse alchemy, going from a normal newborn with almost unlimited potential to a diseased, depressed adult? How does one turn gold into lead?" (p. 1).

Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 139

Cicchetti and Blender (2004) point out that predictive factors have been narrowly focused. They state, "…adequate prediction of either disturbance or resilience requires considering

Bowlby (1980) presented the significance of early caregiving experiences on the ability of a neonate to attach to its caregivers, and thus internalize "working models" or representations of positive caregiving experiences. Van der Kolk (2005) states, "A child's internal working models are defined by the internalization of the affective and cognitive characteristics of

For humans, brain development is optimally done in a social context, that is with primary caregivers providing not only sustenance but nurturance as well. When the caregiving relationship is less than optimal or in fact abusive, such as in the cases of neglect or physical

For the CSA survivor's health, neglect may have reverberations on many levels throughout his or her life. Psychological and physical health, interpersonal functioning, and overall well-being are impacted by levels of neglect. A significant consideration is that the CSA survivor may lack the primary belief that he/she is an individual of worth, deserving to take care of her physical health. Therefore, her ability to be an educated health consumer, to ask questions during medical exams, and her ability to follow-up with annual visits, required

The CSA survivor may not have experienced good role models and thus may not have learned that brushing ones teeth every day is a necessary component of good health care. He or she may not have learned about the necessity of hygiene, immunizations, and annual check-ups and treatment for childhood illnesses, such as ear infections. Not having a good role model may have taught her that these types of behaviors are not a necessary part of life

**Posttraumatic Stress Disorder (PTSD), chronic PTSD, and Developmental Trauma Disorder**  CSA survivors can suffer with posttraumatic stress symptomatology and PTSD. PTSD is defined as exposure to a traumatic event in which the threat of death or serious injury or witnessing threat or serious injury or the threat to physical integrity has occurred. In addition, intense fear, helplessness, or horror responses to a traumatic event may have occurred (DSM IV, TR p. 428). Symptomatology include avoidance of the initial traumatizing event or environment, frequent dreams or nightmares of the event, intrusive thoughts and images, flashbacks – feeling as if the event is occurring again – which is generally triggered by sensory stimuli, and physiological reactivity, e.g. a heightened state

Chronic PTSD generally occurs when there is more than one traumatic event and/or if the initial ongoing traumatic event was severe and ongoing, e.g., combat situations. The CSA survivor may have been abused by a family member as a child, experienced dating violence, married an abusive spouse, and/or may have been sexually abused again by a stranger and/or another family member. Very often, these types of lifelong traumatic experiences involve the notion that many survivors carry; that life usually entails traumatic events that

multiple risks and protective factors and their interplay" (p. 17325).

and sexual child abuse, the child will experience deleterious outcomes.

immunizations, and diagnostic testing, etc., may all be compromised.

and certainly not a consideration for good health.

of agitation, motor activity, or physical reactions.

**3. Attachment** 

their primary relationships" (p. 402).
