**7. Discussion**

84 Sexual Abuse – Breaking the Silence

The average abuse lasted 3-4 years (ranging from 1-30 years), and happened 3-4 times a week. Furthermore the prevalence of the various assaults (ranging from 16% to 100%)

b. The moderate to very high incidence of enforcing secrecy measures ranging from 35%

c. The considerable incidence of reported memory recovery, e.g. 41% for males and 57% for females with a mean duration of 8.19 years for males and 11.67 years for females. In

The finding that 71% of the males and 78% of the females reported that the abuse had started before the age of 10 suggests that we are really dealing with *childhood* sexual

Because neither on age nor on any abuse characteristic significant gender differences could be demonstrated, there was no further need for controlling for these variables in the upcoming statistical analyses where gender differences were tested on alexithymia,

Considerable evidence was found for **Hypothesis 1**, stating that CSA-victims display:

A *high prevalence of alexithymia* (e.g. scores ≥ 54.0 on the cognitive component of the BVAQ), as 40% of the CSA subjects (see Table 1 in the next chapter by Moormann, Albach & Bermond on alexithymia, dissociation and memory recovery) could be classified as either Type I (14%) or Type II (26%) alexithymia compared with the common guideline that about 1/5th of the normal population is alexithymic (see Instruments for prevalence statistics).

*High dissociation scores* (DES/28 > 25), as the average DES scores of both male (M = 25.79) and female (M = 38.23) CSA respondents exceeded the optimal cut-off value of 25 (see Table 2), indicative of Dissociative Identity Disorder (DID). Regarding the incidence of severe dissociation it was found that 47% of male and 78% of the females had average DES

A *negative Self* as the average Self scores for male (M = 88.39) and female (M = 71.06) CSA respondents (see Table 2) were far below the cut-off value for students (N = 1061) corresponding to ≤ percentile 30 (Mean LSQ ≤ 103). Unfortunately norms for the normal population were not yet available. However compared with the elderly (N = 30; 74-98 years of age) the scores of both male and female CSA respondents were also far below the cut-off value of 98, corresponding to values lower than percentile 25. Compared with poly hard drug addicts, known for a negative self, the average mean self scores of both male and female CSA respondents fell in stanine 4 (for norm references see

a. The high incidence of coercion measures ranging from 51% to 92%,

one case a memory recovery had been reported after 46 years.

**6.2 Impact of CSA on alexithymia, dissociation and self** 

indicates severe abuse when considering:

to 94%, and

dissociation and self.

abuse.

scores > 25

Instruments).

**6.3 Explorative part: Gender differences** 

In Table 2 the statistics for this paragraph are given.

#### **7.1 Impact of CSA on alexithymia, dissociation and self**

Subjects in our sample have been victims of severe CSA and the results on alexithymia, dissociation, self and memory recovery confirm the notion that severe CSA has a devastating effect on psychological health in adulthood. The incidence of alexithymia (40%) was found to be substantially higher than the statistics published in non-abused populations in various different countries (around 20%; see the BVAQ description in the instruments part). Furthermore it was found that 47% of males and 78% of the females had average DES scores > 25, indicating DID. Finally CSA respondents reported a negative self. The outcomes above can be criticized on a common problem with prevalence indices for psychological disorders, e.g. where the exact cut off value should be located to ensure a valid diagnosis of alexithymia, dissociation or self. To some extent cut off scores always remain arbitrary and subjective. Even when sensitivity and specificity requirements are fulfilled the choice of the criterion remains an arbitrary decision. Furthermore the reliability on the reported abuse characteristics, a common problem in all retrospective studies using self-report questionnaires, can be questioned as well.

Gender Differences in the Impact of Child Sexual Abuse on Alexithymia, Dissociation and Self 87

diminished interest in others, feelings of detachment, a restricted range of affect, and dissociation. Emotional numbing and diminished interest in others, particularly during development, may result in lack of empathy and an increased risk for anti-social behaviors

**7.4 Incongruence between what is expected from the neurobiological substrate on** 

However, our results on gender differences are the opposite of what would be expected from a neurobiological perspective. How can this be explained? De Bellis and Keshavan note that their cross-sectional investigation does not imply causation. Neither does our investigation. It is not possible to disentangle whether observed sex differences are the consequence of the stress and trauma or a preexisting risk factor for the development of a disorder. It might well be that the male subjects in our sample did not have a preexisting risk factor but instead a preexisting protective buffer (low levels of neuroticism) against the development of a specific disorder. In this context it should be noted that only seventeen male respondents were willing to volunteer in our research. They were hard to find. There is still a 'taboo' on talking about male sexual abuse, in particular because it concerned same-sex relationships, which could make others think the victim consented to the abuse and is homosexual. It might well be that the male respondents who were willing to share their experiences with others were the stronger ones with more healthy personality profiles (lack of neuroticism), who were better equipped to cope with the

Even though our findings are not in agreement with what could be expected from a neurobiological point of view they do correspond to the general notion that women display a higher level of symptom reporting than men (Wool & Barsky, 1994; Kroenke & Spitzer, 1998). However it should be noted as well that one of the more controversial issues in terms of mental disorder diagnoses has been their differential sex prevalence (Hartung & Widiger, 1998). The point to be made is that it cannot be denied that what is suggested by neurobiological studies, e.g. that males are more vulnerable to the effects of severe stress in global brain structures than females, does not always correspond to what has been reported on the behavioral level in symptomatology. Hence, it remains striking that women who on the neurobiological level are assumed to be less vulnerable to stress (the stronger sex) have on the behavioral level both a reputation for and do show the symptoms of vulnerability to stress in a wide array of activities (the weaker sex). It might well be that the immensely popular brain model in contemporary academic science also has its flaws and does not account yet for the more phenomenological (how people experience events and impressions) aspects of human existence. Anyway we sincerely hope that our research with all its weaknesses and limitations is challenging enough to stimulate future research on the

CSA-victims display: 1) a high prevalence of alexithymia (40% as opposed to 20%, reported in general populations), 2) high dissociation scores (> 25 on the average DES), indicative of

**gender differences in symptomatology and its behavioral manifestation** 

and externalizing behaviors.

adverse effects of CSA.

**8. Conclusions** 

virgin territory of gender differences in CSA.

Dissociative Identity Disorder, and 3) a negative self.

#### **7.2 Gender specific outcomes**

The impact for female victims was significantly stronger than for male victims (see Table 2). This result parallels the outcomes of gender differences in normal populations. Women generally have both stronger dissociative tendencies and a more negative self. However, in general men are more alexithymic and less emotional than women. Our results indicate the contrary, e.g. CSA women were found to be significantly more alexithymic than men, but only on the cognitive component (reduced Verbalizing and Identifying). The credibility issue, discussed in the introduction, and still associated with the feminine stereotype (hysterical, emotional, fantasy prone, liar, etc.) might be responsible for the highly impaired cognitive component in women, as not being taken seriously by expressing doubts on the credibility of their accounts, hampers the formation between the emotional experience and its cognitive labels. This invalidating environment where cries for help of the abused child are ignored or denied, often even by the mother, is described by Huber (1997) as one of the four factors associated with the development of DID. On the affective component (reduced Fantasizing and Emotionalizing) however, the sexes did not differ significantly from each other, which is remarkable as well because women usually are more emotional than men (Carpenter & Addis). The reported gender differences cannot be attributed to particular abuse characteristics because the sexes didn't differ significantly on any characteristic (see Table 1). It should be noted that in one category, e.g. 'perpetrator', only t-tests where the father had been the perpetrator (29% for males, 40% for females) could be performed, as in all other cases one of the groups contained empty cells. The data on perpetrators suggest, that adult relatives (grandfather, uncle) and strangers more often abused girls, while older siblings and adults they knew well, other than relatives (teachers, priests, coaches in sport clubs, etc.), more often abused boys. As it is extremely difficult to escape abuse in invalidating environments if an adult relative is the perpetrator it might be that threatening, physical violence and other coercions employed by the perpetrator to enforce secrecy (don't tell anybody about our secret otherwise …) have led to the reported higher impairment of the cognitive alexithymia component in combination with higher dissociation scores in female victims.

#### **7.3 Gender differences from a neurobiological perspective**

An alternative way of discussing the results is looking for neurobiological substrates explaining behavioural gender differences. Larger prefrontal lobe CSF volumes and smaller midsaggital area of the corpus callosum subregion 7 (splenium) were seen in both boys and girls with maltreated-related PTSD (De Bellis & Keshavan, 2003). Subjects with PTSD did not show the normal age related increases in the area of the total corpus callosum and splenium. However this finding was more prominent in males with PTSD. Significant sex by group effects demonstrated smaller cerebral volumes and corpus callosum regions 1 (rostrum) and 6 (isthmus) in PTSD males and greater lateral ventricular volume increases in maltreated males with PTSD than maltreated females with PTSD. According to De Bellis and Keshavan their findings suggest that males are more vulnerable to the effects of severe stress in global brain structures than females. In the well-controlled, highly elegant study of De Bellis and Keshavan maltreated males with PTSD did show a trend towards reporting of more cluster C symptoms (e.g. avoidant and dissociative behaviors) than maltreated females with PTSD. The associated behavior includes efforts to avoid traumatic reminders, diminished interest in others, feelings of detachment, a restricted range of affect, and dissociation. Emotional numbing and diminished interest in others, particularly during development, may result in lack of empathy and an increased risk for anti-social behaviors and externalizing behaviors.

#### **7.4 Incongruence between what is expected from the neurobiological substrate on gender differences in symptomatology and its behavioral manifestation**

However, our results on gender differences are the opposite of what would be expected from a neurobiological perspective. How can this be explained? De Bellis and Keshavan note that their cross-sectional investigation does not imply causation. Neither does our investigation. It is not possible to disentangle whether observed sex differences are the consequence of the stress and trauma or a preexisting risk factor for the development of a disorder. It might well be that the male subjects in our sample did not have a preexisting risk factor but instead a preexisting protective buffer (low levels of neuroticism) against the development of a specific disorder. In this context it should be noted that only seventeen male respondents were willing to volunteer in our research. They were hard to find. There is still a 'taboo' on talking about male sexual abuse, in particular because it concerned same-sex relationships, which could make others think the victim consented to the abuse and is homosexual. It might well be that the male respondents who were willing to share their experiences with others were the stronger ones with more healthy personality profiles (lack of neuroticism), who were better equipped to cope with the adverse effects of CSA.

Even though our findings are not in agreement with what could be expected from a neurobiological point of view they do correspond to the general notion that women display a higher level of symptom reporting than men (Wool & Barsky, 1994; Kroenke & Spitzer, 1998). However it should be noted as well that one of the more controversial issues in terms of mental disorder diagnoses has been their differential sex prevalence (Hartung & Widiger, 1998). The point to be made is that it cannot be denied that what is suggested by neurobiological studies, e.g. that males are more vulnerable to the effects of severe stress in global brain structures than females, does not always correspond to what has been reported on the behavioral level in symptomatology. Hence, it remains striking that women who on the neurobiological level are assumed to be less vulnerable to stress (the stronger sex) have on the behavioral level both a reputation for and do show the symptoms of vulnerability to stress in a wide array of activities (the weaker sex). It might well be that the immensely popular brain model in contemporary academic science also has its flaws and does not account yet for the more phenomenological (how people experience events and impressions) aspects of human existence. Anyway we sincerely hope that our research with all its weaknesses and limitations is challenging enough to stimulate future research on the virgin territory of gender differences in CSA.

### **8. Conclusions**

86 Sexual Abuse – Breaking the Silence

The impact for female victims was significantly stronger than for male victims (see Table 2). This result parallels the outcomes of gender differences in normal populations. Women generally have both stronger dissociative tendencies and a more negative self. However, in general men are more alexithymic and less emotional than women. Our results indicate the contrary, e.g. CSA women were found to be significantly more alexithymic than men, but only on the cognitive component (reduced Verbalizing and Identifying). The credibility issue, discussed in the introduction, and still associated with the feminine stereotype (hysterical, emotional, fantasy prone, liar, etc.) might be responsible for the highly impaired cognitive component in women, as not being taken seriously by expressing doubts on the credibility of their accounts, hampers the formation between the emotional experience and its cognitive labels. This invalidating environment where cries for help of the abused child are ignored or denied, often even by the mother, is described by Huber (1997) as one of the four factors associated with the development of DID. On the affective component (reduced Fantasizing and Emotionalizing) however, the sexes did not differ significantly from each other, which is remarkable as well because women usually are more emotional than men (Carpenter & Addis). The reported gender differences cannot be attributed to particular abuse characteristics because the sexes didn't differ significantly on any characteristic (see Table 1). It should be noted that in one category, e.g. 'perpetrator', only t-tests where the father had been the perpetrator (29% for males, 40% for females) could be performed, as in all other cases one of the groups contained empty cells. The data on perpetrators suggest, that adult relatives (grandfather, uncle) and strangers more often abused girls, while older siblings and adults they knew well, other than relatives (teachers, priests, coaches in sport clubs, etc.), more often abused boys. As it is extremely difficult to escape abuse in invalidating environments if an adult relative is the perpetrator it might be that threatening, physical violence and other coercions employed by the perpetrator to enforce secrecy (don't tell anybody about our secret otherwise …) have led to the reported higher impairment of the cognitive alexithymia component in combination with higher dissociation scores in

**7.2 Gender specific outcomes** 

female victims.

**7.3 Gender differences from a neurobiological perspective** 

An alternative way of discussing the results is looking for neurobiological substrates explaining behavioural gender differences. Larger prefrontal lobe CSF volumes and smaller midsaggital area of the corpus callosum subregion 7 (splenium) were seen in both boys and girls with maltreated-related PTSD (De Bellis & Keshavan, 2003). Subjects with PTSD did not show the normal age related increases in the area of the total corpus callosum and splenium. However this finding was more prominent in males with PTSD. Significant sex by group effects demonstrated smaller cerebral volumes and corpus callosum regions 1 (rostrum) and 6 (isthmus) in PTSD males and greater lateral ventricular volume increases in maltreated males with PTSD than maltreated females with PTSD. According to De Bellis and Keshavan their findings suggest that males are more vulnerable to the effects of severe stress in global brain structures than females. In the well-controlled, highly elegant study of De Bellis and Keshavan maltreated males with PTSD did show a trend towards reporting of more cluster C symptoms (e.g. avoidant and dissociative behaviors) than maltreated females with PTSD. The associated behavior includes efforts to avoid traumatic reminders,

CSA-victims display: 1) a high prevalence of alexithymia (40% as opposed to 20%, reported in general populations), 2) high dissociation scores (> 25 on the average DES), indicative of Dissociative Identity Disorder, and 3) a negative self.

Gender Differences in the Impact of Child Sexual Abuse on Alexithymia, Dissociation and Self 89

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**Part 2** 

**The Physiological Impact of Sexual Assault** 

