**4. How does trauma change your health?**

Traumatic events are now known to change not only psychological well-being but also the basic structure of how the body perceives painful events, processes them and produces physical reactions. But how does this happen? How do traumatic events in childhood such as sexual abuse change health status? It is important to note that not all individuals exposed to traumatic events will experience noxious outcomes, therefore genetic predisposition/vulnerability (Neigh, Gillespie, Nemeroff, 2009) and environmental factors are suspected when examining etiology. Stern's oft quoted metaphor (Kazaks & Stern, 2005) "Genetics load the gun, and environment pulls the trigger," appears apropos.

Humans have the capacity to react to stressful events in ways that will protect them. Many people have heard of the fight/flight/freeze reaction to threatening events. This is the body's stress reaction alerting the individual to either stay and fight, run away from the stressful event, or sometimes freeze in place. Each reaction is designed to assist the individual to survive and is directly attributable to the autonomic nervous system and the endocrine system working together to deal with the stressful event.

one cannot escape. CSA survivors with chronic PTSD often experience hyperarousal and hypervigilience that are continuous physiological states. Chronic PTSD frequently includes the inability to self-soothe and emotionally regulate. Health risk behaviors such as alcohol and substance abuse, cigarette smoking, eating disorders, and self-injurious behavior (cutting) are correlated with childhood sexual abuse. These health risk behaviors can be considered attempts by the CSA survivor, albeit poor ones, in the adaptive struggle in which self-medicating is necessary for survival. They may also be attempts to avoid intrusive

The sexual abuse field has struggled with the inadequacy of the PTSD diagnosis for child victims of sexual abuse. Because the nature of sexual abuse is chronic, usually perpetrated by a caregiver, and occurs during childhood, it impacts critical periods of neurobiological development (van der Kolk, 2011). When caregivers are abusive, absent or neglectful, and/or helpless in the face of trauma, children cannot develop a sense of safety and stability that emanates from the caregiver nor can they rely on that caregiver to restore a sense of calm and reliability. The child's responses to stress become diffuse and inadequate. The ability to self-soothe and emotionally regulate – managing stress, impulsivity, and anxiety – are markedly impaired. A significant issue is that the child experiences a sense of betrayal

Mental health practitioners and researchers have examined the concept of complex PTSD (Herman, 1992a, 1992b) and the tentative diagnosis of Developmental Trauma Disorder (Cook et al, 2005; van der Kolk, 2005). Cook et al (2005) state, "A comprehensive review of the literature on complex trauma suggest seven primary domains of impairment observed in (traumatically) exposed children: attachment, biology, affect regulation, dissociation, (e.g., alterations in consciousness), behavioral regulation, cognition, and self-concept" (p. 392). Included in these domains are the child's worldview and functional impairments such as academic, interpersonal, legal interactions, and vocation (van der Kolk, 2005). This tentative diagnosis, yet to be wholly accepted by the trauma field, appears to encompass the chronic

Traumatic events are now known to change not only psychological well-being but also the basic structure of how the body perceives painful events, processes them and produces physical reactions. But how does this happen? How do traumatic events in childhood such as sexual abuse change health status? It is important to note that not all individuals exposed to traumatic events will experience noxious outcomes, therefore genetic predisposition/vulnerability (Neigh, Gillespie, Nemeroff, 2009) and environmental factors are suspected when examining etiology. Stern's oft quoted metaphor (Kazaks & Stern, 2005)

Humans have the capacity to react to stressful events in ways that will protect them. Many people have heard of the fight/flight/freeze reaction to threatening events. This is the body's stress reaction alerting the individual to either stay and fight, run away from the stressful event, or sometimes freeze in place. Each reaction is designed to assist the individual to survive and is directly attributable to the autonomic nervous system and the

"Genetics load the gun, and environment pulls the trigger," appears apropos.

endocrine system working together to deal with the stressful event.

and perceives the world as a hostile and attacking environment.

and devastating nature of trauma to the developing child.

**4. How does trauma change your health?** 

memories.

The hypothalamic-pituitary-adrenal (HPA) axis is a mediating pathway of the stress response (Neigh, Gillespie, Nemeroff, 2009, van der Kolk, 2011) and it's the function of the HPA to modulate hormones that address stressful events. To promote survival, a chain reaction of powerful hormones and neurochemicals are produced to assist the individual in dealing with the immediate stressful event (Neigh, Gillespie, Nemeroff, 2009). Deactivation of these hormones occurs through a "negative feedback loop" alerting the individual that danger is no longer present. Neigh, Gillespie, and Nemeroff (2009) state,

However, if the stress response becomes chronic due to repeated exposure to stressors, defects at different levels of the negative feedback system, or both, the result is a sustained increase in the level of stress hormones and the initiation of pathological changes across multiple physiological systems, resulting in stress related diseases (p. 391; also see McEwen, 2008).

The sympathetic nervous system (SNS) is dominant over the parasympathetic nervous system (PNS), and will not yield to the PNS until some form of resolution takes place. Resolution can take the form of fighting, jogging, meditating (Howard, 2006). The adrenal glands release enough adrenaline to get your attention at the first sign of stress. Adrenaline also helps to "imprint" an emotional or traumatizing event. If the stress continues, the hypothalamus secretes corticotropin-releasing factor. In this process cortisol is also released.

Cortisol is a steroid hormone that is produced naturally in the body to assist in the adaptive struggle when an individual is facing acute traumatic situations. When the stress or the traumatic situation is chronic, high levels of cortisol become toxic. Prolonged cortisol production impairs the immune system and thus, healing. Vulnerability to stress-related disorders and diseases, such as gastrointestinal disorders (ulcers) and heart disease commences. Chronic trauma and stress induces lower cortisol production and this decrease creates an enhanced autoimmune system. In the absence of any other illnesses, the autoimmune system will attack various systems within the body and create illnesses such as Fibromyalgia, Chronic Fatigue Syndrome, thyroid diseases, and Krohn's disease (Bergmann, 2011). Howard (2006) states,

Minor results of this stress-related impairment include colds, flu, backaches, tight chest, migraine headaches, tension headaches, allergy outbreaks, and skin ailments. More chronic and life-threatening results can include hypertension, ulcers, accidentproneness, addictions, asthma, infertility, colon or bowel disorders, diabetes, kidney disease, rheumatoid arthritis, and mental illness. Killers that can result include heart disease, stroke, cancer, and suicide (p. 816).

Chronic trauma, coupled with the severity of the abuse itself, has long-term devastating impact on health and mental health due to the chronicity of these physiological states.

### **5. Mental health features of the CSA survivor that impede their health outcomes**

CSA survivors may experience shame and self-blame regarding the sexual abuse and approach both mental health practitioners and health professionals with distrust, fear, and anxiety. CSA survivors may also experience a range of PTSD symptomatology that includes avoidant behaviors, depression, and dissociation.

Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 143

2011). All of these factors modulate functional aspects of the gastrointestinal system and later, symptoms. While IBS is influenced by several factors such as genetics, environment,

Gynecological problems such as difficult menses and pain when having sexual intercourse, sexual performance, as well as promiscuity, may also contribute to poor reproductive health

CSA survivors may also suffer from Immune System Dysfunction, musculoskeletal difficulties, respiratory ailments such as Asthma, and rheumatic disorders. CSA survivors can also experience what is called Medically Unexplained Symptoms (MUS) such as fibromyalgia (Roelofs & Spinhoeven (2009). Other types of difficulties include urinary tract infections, migraine headaches, chronic pelvic pain and pain intolerance or sensitivity.

Addictive behaviors that lead to poor health outcomes are also associated with childhood sexual abuse such as eating disorders (anorexia, bulimia, and obesity), substance abuse (alcohol and/or drugs), and cigarette smoking. Table 1 lists the most common medical

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,

and family environment, childhood sexual abuse is a contributing factor.

outcomes.

conditions for CSA survivors.

 Autoimmune Diseases Cardiovascular Disease

Gynecological Issues

Rheumatic Disorders

Diabetes

 Pain Perception and Chronic Pain Compromised Reproductive Health

 Immune System Dysfunction Musculoskeletal difficulties Respiratory Ailments (Asthma)

Eating Disorders (Anorexia, Obesity, Bulimia)

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

Gastrointestinal Disorders (Irritable Bowel Syndrome)

Medically Unexplained Symptoms (MUS) e.g., fibromyalgia

Table 1. Common Medical Difficulties Reported By CSA Survivors

The survivor may not have had good health care models to emulate or his or her health care needs may have been neglected and minimized. Cycles of negative emotions, stress, pain and self-defeating beliefs may perpetuate physical problems. Years of avoidant behavior regarding health issues may have passed before the CSA survivor reaches the health care professional, thus warranting more intensive and costly treatment.

### **6. Health risk behaviors**

In an effort to self-soothe, the CSA survivor may have tried to self-medicate using a variety of maladaptive behaviors and methods. No one would doubt that the prevalence of addiction difficulties with substances such as drugs and alcohol in the United States is of epidemic proportion. Eating disorders, closely correlated with sexual abuse, is a mental health difficulty with severe physical consequences. Unprotected sex, sexually risky behaviors, and prostitution have their etiology in sexual abuse trauma (Tarakeshwar, Fox, Ferro, Khawaja, Kochman, Sikkema, 2005). Self-injurious behavior such as skin carving has long been thought to alleviate some of the internal stress experienced by CSA survivors.

### **7. Medical issues**

Before reviewing the medical issues of CSA survivors one must consider the often mistaken assumption that the somatic complaints of the survivor have no physical etiology, and therefore they are often overlooked and/or misdiagnosed. This phenomenon occurs both with the health and mental health care professional as well as the CSA survivor.

Psycho-physiological changes coupled with psychological changes create multi-systemic problems common to CSA survivors. The American Medical Association 1992 addresses these changes when they state,

The event has such physiological and psychological intensity that it overrides and impairs the individual's neurophysiological mechanisms of adaptation. The resulting damage is not merely emotional. The person's biological capacity to tolerate and regulate internal and external stimulation can be altered. These changes, in turn, compromise the person's ability to organize perceptual stimuli and cognitive information, making them susceptible to a range of somatic illnesses and a spectrum of anxiety and depressive disorders (p 35).

Psychological distress also contributes to the CSA survivor having an impaired view of their health either through somatization and/or dissociation.
