**12. Phase III**

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 attend to their healthcare needs as an adult.

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, & Minton, 2000) during all the phases of therapy.

#### **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 control.

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 patient.

Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 149

American Medical Association, Council on Scientific Affairs (1992). Guidelines for Medical

Alexander, F.G. & French, T.M. (1946). *Psychoanalytic Therapy, Principles and Application*,

American Medical Association (1995). *Diagnostic & Treatment Guidelines on Mental Health* 

American Psychiatric Association. *Diagnostic and Statistical Manual of Mental Disorders, 4th ed, text revision*. Washington, D.C: American Psychiatric Association, 2000 Bergmann, U. (2011). *Foundations of Neurobiology for EMDR Practice*. New York: Springer

Boscarino, J. A. (2004). Posttraumatic Stress Disorder and Physical Illness, Results from

Briere, J. & Elliott, D.M. (2003). Prevalence and symptomatic sequelae of self-reported

Briere J. & Scott, C. (2006). *Principles of Trauma Therapy*. Thousand Oaks, CA: Sage

Briere, J., Scott, C., & Weathers, F. (2005). Peritraumatic and persistent dissociation in the presumed etiology of PTSD. *American Journal of Psychiatry*, 162, 2295-2301. Brown, D. (2009). Assessment of attachment and abuse history, and adult attachment style.

Courtois and Julian D. Ford (Eds.). New York: Guilford Press, pp. 124- 126. Browne, A. & Finkelhor, D. (1986). The impact of child sexual abuse: A review of the

Cicchetti, D. & Blender, J.A. (2004). A Multiple-Levels-of-Analysis Approach to the Study of

Courtois, C. (2005). When One Parent Has been Sexually Abused As A Child. Family

Chartier, M.J., Walker, J., & Naimark, B. (2008). Health Risk Behaviors and Mental Health

Drossman, D. (1994). Physical and Sexual Abuse and Gastrointestinal illness: What is the

Eke, P.I, Thornton-Evans, G.O., Wei, L, Borgnakke, W.S., Dye, B,A. (2010). Accuracy of NHANES Periodontal Examination Protocols, *Journal of Dental Research*, Finkelhor, D. (1984). *Child Sexual Abuse: New Theory and Research*, New York: The Free Press. Felitti, V.J., Anda, RF, Nordenberg, D., Williamson, DF, Spitz, AM, Edwards, V, Koss, M.P,

Health. *American Journal of Public Health*, 10.2105/AJPH.2007.122408. Cook, A., Spinazzola, J., Ford, J., Lanktree, C., Blaustein, M., Cloitre, M., DeRosa, R. et al

Clinical and Epidemiologic Studies, *Annals of the New York Academy of Science*, 1032,

childhood physical and sexual abuse in a general population sample of men and

In *Treating Complex Traumatic Stress Disorders, An Evidence-Based Guide.* Christine A.

Developmental Processes In Maltreated Children. *Proceedings of the National*

*Stressors, Interventions for Stress and Trauma*. Don R. Catherall (Ed). New York, N.Y:

Problems as Mediators of the Relationship Between Childhood Abuse and Adult

(2005). Complex Trauma in Children and Adolescents. *Psychiatric Annals*, 35(5),

Marks, J.S. (1998). The Relationship of Adult Health Status to Childhood Abuse and

Settings Regarding Violence Against Women. Chicago, IL: AMA.

University of Nebraska Press, John Wiley.

*Effects of Family Violence*. Chicago, IL: AMA.

women. *Child Abuse & Neglect*, 27, 1205-1222.

literature. *Psychological Bulletin*, 99(1), 66-77.

Link? *American Journal of Medicine*, 97, 105-107.

*Academy of Sciences*, December.

Taylor & Francis, pp. 95-111.

Bowlby, J. (1980). *Attachment and Loss*, *Vol 3*. New York, N.Y.: Basic Books

**14. References** 

Publishing.

141-153.

Publications.

390-398.

Mrs. N, 65 years old, woke up in the recovery room after a colonoscopy, screaming that a man was coming after her. The doctor was called in after the nurse could not calm her. She was able to tell the doctor that the man was a neighbor who had attacked her sexually and that she had not remembered anything about him in almost 60 years. She became very disoriented, weepy and had to be sedated. For several weeks she did not "feel like herself" and her family doctor referred her to a psychiatrist who medicated her and recommended that she see a trauma therapist. She grew to trust the therapist who was soft spoken and reminded her of her grandmother, even though the therapist was younger than Mrs. N. The therapist normalized the long-term dissociation and amnesia as survival techniques for a little girl who had alcoholic, unprotective parents. Mrs. N. stated that they were usually too drunk to listen or protect her and her siblings. The therapist was trained in Eye Movement Desensitization and Reprocessing (EMDR) a phase-oriented therapy validated for the treatment of PTSD. It included all of the three phases of trauma treatment as mentioned above plus a desensitization, reprocessing, and evaluation phases. As she learned relaxation exercises and practiced them in between sessions, she felt stronger and more in control of her life. She learned about triggers and made the connection between the colonoscopy and the childhood anal rape. Several months after, she felt strong enough to rehearse a planned visit to a gynecologist to discuss exploratory laparoscopic surgery for ovarian cysts. Both she and the therapist felt that she had completed the trauma work and would not be triggered by the procedure. She did tell the doctor about the earlier abuse and the incident triggered by the colonoscopy. They planned that the nurse would sit with her in the recovery room and say to her, "Hello Mrs. N. I'm here with you now. Would you like a drink of water?" That would be a cue that she was in the present, a common grounding technique. Her husband would also be brought right in and would hold her hand to provide comfort. There were several weeks of rehearsal and the medical protocol went well.

#### **13. Conclusion**

During the past ten years there has been a proliferation of research and clinical studies in the medical, dental, and mental health journals that unequivocally supports that childhood sexual abuse is epidemic and detrimental to the mental, physical and dental health of survivors. It has been defined as a public health issue, yet changes in bringing this knowledge and clinical expertise to core curricula (and not as an elective or special course) in Medical, Dental, Mental Health or Nursing Graduate programs has been slow. Collaboration with health professionals and mental health practitioners increases the probability that CSA survivors will begin to enjoy good health. One means toward that end is educating practitioners from all health fields on the issues of child sexual abuse and negative health outcomes.

The incidence and prevalence rates of child sexual abuse have held constant since we began collecting statistics in the late sixties. The human suffering and negative health outcomes of so many are only one part of this social problem. The financial expenses of medical and pharmaceutical needs, time lost at work, psychotherapy costs and substance abuse treatment, family support and help for survivors' children makes this a social problem whose immediacy cannot be ignored. Isn't it time to turn lead into gold?

#### **14. References**

148 Sexual Abuse – Breaking the Silence

Mrs. N, 65 years old, woke up in the recovery room after a colonoscopy, screaming that a man was coming after her. The doctor was called in after the nurse could not calm her. She was able to tell the doctor that the man was a neighbor who had attacked her sexually and that she had not remembered anything about him in almost 60 years. She became very disoriented, weepy and had to be sedated. For several weeks she did not "feel like herself" and her family doctor referred her to a psychiatrist who medicated her and recommended that she see a trauma therapist. She grew to trust the therapist who was soft spoken and reminded her of her grandmother, even though the therapist was younger than Mrs. N. The therapist normalized the long-term dissociation and amnesia as survival techniques for a little girl who had alcoholic, unprotective parents. Mrs. N. stated that they were usually too drunk to listen or protect her and her siblings. The therapist was trained in Eye Movement Desensitization and Reprocessing (EMDR) a phase-oriented therapy validated for the treatment of PTSD. It included all of the three phases of trauma treatment as mentioned above plus a desensitization, reprocessing, and evaluation phases. As she learned relaxation exercises and practiced them in between sessions, she felt stronger and more in control of her life. She learned about triggers and made the connection between the colonoscopy and the childhood anal rape. Several months after, she felt strong enough to rehearse a planned visit to a gynecologist to discuss exploratory laparoscopic surgery for ovarian cysts. Both she and the therapist felt that she had completed the trauma work and would not be triggered by the procedure. She did tell the doctor about the earlier abuse and the incident triggered by the colonoscopy. They planned that the nurse would sit with her in the recovery room and say to her, "Hello Mrs. N. I'm here with you now. Would you like a drink of water?" That would be a cue that she was in the present, a common grounding technique. Her husband would also be brought right in and would hold her hand to provide comfort. There were several weeks

During the past ten years there has been a proliferation of research and clinical studies in the medical, dental, and mental health journals that unequivocally supports that childhood sexual abuse is epidemic and detrimental to the mental, physical and dental health of survivors. It has been defined as a public health issue, yet changes in bringing this knowledge and clinical expertise to core curricula (and not as an elective or special course) in Medical, Dental, Mental Health or Nursing Graduate programs has been slow. Collaboration with health professionals and mental health practitioners increases the probability that CSA survivors will begin to enjoy good health. One means toward that end is educating practitioners from all health fields on the issues of child sexual abuse and

The incidence and prevalence rates of child sexual abuse have held constant since we began collecting statistics in the late sixties. The human suffering and negative health outcomes of so many are only one part of this social problem. The financial expenses of medical and pharmaceutical needs, time lost at work, psychotherapy costs and substance abuse treatment, family support and help for survivors' children makes this a social problem

whose immediacy cannot be ignored. Isn't it time to turn lead into gold?

of rehearsal and the medical protocol went well.

**13. Conclusion** 

negative health outcomes.


Childhood Sexual Abuse and Adult Physical and Dental Health Outcomes 151

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245-258.

597.

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1458.

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Household Dysfunction. *American Journal of Preventative Medicine,* vol. 14, no 4, pp.


**10** 

*Brazil*

**Child Sexual Abuse and** 

*University of the State of Rio de Janeiro* 

**Its Implications for Children's Health** 

Lia Leão Ciuffo and Benedita Maria Rêgo Deusdará Rodrigues

The violence is present in the everyday life of citizens all over the world and in national and regional level too, affecting interpersonal relationships and influencing people's way of

Violence is presented as a complex problem that affects, everybody without distinction, independent of social class, race, religion, sex or age. Today it is more studied, investigated and divulged and because of that it has acquired an important social meaning in the few

The factors that contribute to violent responses – whether they are factors of attitude and behavior or related to larger social, economic, political and cultural conditions – can be changed. In this perspective, understanding the factors that increase the risk of young people being the victims or perpetrators of violence is essential for developing effective

However, we can note that the boundaries between different types of violence aren't well defined, so we must carefully examine all aspects of family violence, and particularly sexual abuse cases, seeking to get a better comprehension about the framework that professional

In general, hearing about real cases of sexual abuse cause on people a feeling of malaise. Sexual violence affects many layers of society and people of different ages, including children and adolescents. Reports of such aggression against a child who probably had been induced or coerced and even forced to participate in such an act unfortunately are common. In this sense, report and prevent child sexual abuse and other crimes against children is a worldwide concern. The cases reported on television and in newspapers of general circulation represent only the tip of the iceberg. If thoroughly investigated, it may be noted that a large number of boys and girls are subjected to violence of all kinds in their daily

The interactions that individuals establish in society, economic issues, policies and legal requirements that govern society help us understand more clearly the various forms of

**1. Introduction** 

acting and thinking.

faces. (Ciuffo, 2008)

lives. (Ciuffo, 2008)

violence and, among them, child sexual violence.

years. (Moura & Lisboa, 2005)

**1.1 Contextualizing violence and child sexual abuse** 

policies and programmes to prevent violence. (Krug et al, 2002)

