Sexual abuse is defined by the World Health Organization (Krug et. al, 2002), as “any sexual act, attempt to obtain a sexual act, unwanted sexual comments or advances, or any other action directed against a person’s sexuality using coercion, by any person regardless of their relation to the victim, in any setting, including but not limited to home and work.” Additionally, coercion may involve physical force, psychological intimidation, blackmail or other threats or may occur when the person aggressed is unable to give consent, for instance when drugged, asleep or mentally incapable of understanding the situation. The information available in the literature pertains mostly to women, within the United States, who have been abused, but sexual abuse is not limited to women. While there are limited studies conducted on sexually abused men, the prevalence of male sexual abuse ranges between 3%- 31% of men in child, adult, criminal, and non criminal populations, compared with the range of 6%-62% for women (Finkelhor 1986; Scher, et al., 2004). The gender differences in frequency of sexual abuse could be attributed to either under reported male sexual abuse cases or lower frequency of sexual abuse towards men.
Child sexual abuse (CSA), adult sexual abuse (ASA), and intimate partner violence are all types of sexual abuse. While all these different types of abuse are likely to affect sexual function, the majority of the studies on the topic remain descriptive, meaning that little is known about how and why sexuality is affected; or how to treat sexual dysfunctions that are commonly reported by individuals with a history of sexual abuse. Furthermore, the majority of studies have focused on the sexual function of women who have experienced CSA or have a history of both CSA and ASA; very little is known about the sexuality of women who have been abused during adulthood only.
The legal definition of sexual abuse varies from the definition utilized by researchers and understanding the nuances of this definition is important to better interpret the results from scientific studies on the sexuality of sexual abuse survivors. Researchers classify CSA based on the age of the individual when the abuse begun, the age of the perpetrator(s), the type of sexual behaviors that occurred, and the subjective experience of the child (i.e., feeling forced, coerced, or seduced). The most frequent definition of CSA, used by researchers, is the act of engaging in a wanted or unwanted sexual act before the age of 18 with someone 5 or more years older or being coerced into an undesired sexual act, before the age of 18, with someone of any age (Loeb et al., 2002). A sexual act is not limited to penetration of the vagina or anus, but may be considered as any sexual caress, touch, or kiss involving the genitals of the victim or the victim caressing, touching, or kissing the perpetrator against his or her will. Despite this definition being the most common one, researchers vary greatly in the definitions they adopt in their studies. Some researchers define childhood sexual abuse as an incident occurring before the age of 12, some before the age of 16, and others before the age of 18. Definitions also vary based on the severity of abuse (penetration, threats to survivor, or duration of abuse) and degree of familiarity the survivor has to the abuser, with some definitions requiring reports of physical force and genital penetration and others focusing on any type of unwanted sexual act, including being forced to view sexually explicit material against one’s will.
Overall, studies on CSA prevalence consistently indicate that, contrary to common beliefs, in 70% to 90% of cases, the survivor is violated by a familiar person (a family member or custodian or another trusted adult such as a neighbor, teacher, babysitter, coach, religious leader, or a peer) rather than a stranger (Finkelhor 1994). Indeed, between1/3 and ½ of reported cases involve a family member as the perpetrator (Finkelhor 1994). News of children abducted and abused by strangers is indeed a rare phenomenon that we may consider more common because of the disproportionate media coverage of this type of abuse compared to the treatment of sexual victimization occurring within the family system.
The definition of adult sexual abuse is less controversial. Adult sexual abuse is an unwanted sexual act after the age of 18. The perpetrator may be an intimate partner, a familiar person, or a stranger (Finkelhor 1994). One study documented nearly 50% of women reported being in a sexually or physically abusive relationship (defined as a cohabiting relationship lasting more than three months) with an intimate partner at some point in their lives (Tjaden 2000). Of those, 22% of women reported being abused sexually (defined as partner hurting the woman during sex, physically forcing her to have sex, or injuring her breast or genitals) with or without physical abuse. For reasons that remain mostly unexplained, individuals who have been sexually abused by an intimate partner in the past are twice as likely to be abused by a future partner (Coker 2000). Women who have experienced multiple abuses report higher levels of dysfunctional sexual behavior and intrusive thoughts during sex as well as a greater fear of intimacy (Davis, Petretic-Jacksom, and Ting, 2001).
It should be kept in mind that researchers are incapable of clearly identifying the effect of sexual abuse on sexual functioning. Much of what we know about the effects of sexual abuse on sexual functioning is correlation; meaning we can look at populations of women who have experienced abuse and determine from that population how many women have developed dysfunctions. These studies can be informative in terms of giving us a snapshot of the types of sexual problems commonly experienced by sexual abuse survivors, but cannot be used to make a claim on the effects of sexual abuse on adult sexual functioning. It is impossible to determine exact reasons why women who have experienced sexual abuse develop sexual and relational dysfunctions.
Not all women who experience abuse will be impacted with a sexual dysfunction, a psychological disorder, or relational issues. But any woman who does suffer from such difficulties must know she is not alone in her experience, nor is she alone in the fight for a better understanding of the impact of sexual abuse on all facets of a survivor’s life.
Difficulty in engaging in sexual activity for survivors of sexual abuse is not uncommon. A study (Jehu, 1988) estimated that in a sample of 51 women with a history of CSA, 94% identified struggling with at least one sexual disorder (i.e., low desire, problems becoming sexually aroused, difficulty reaching an orgasm or experiencing pain during sexual intercourse). Hypoactive sexual desire is the lack of sexual fantasies or lack of interest in sexual activity (DSM-IV-TR) and is one of the most commonly reported sexual problem among women with a history of sexual abuse. Across five studies looking at sexual dysfunction in women with a history of CSA, desire dysfunctions were the most persistent affecting between 50% and 59% of participants (Becker, Skinner, Abel, Axelrod, Cichon 1984; Jackson, Calhoun, Amick, Maddever, Habif, 1990; Jehu 1988; Sarwer & Durlack, 1996; Westerlund, 1992).
Sexual arousal difficulties include inability to engage in, maintain until completion, or stay lubricated during sexual activities (DSM-IV-TR). Difficulties with sexual arousal affected 49% to 84% of women with a history of CSA (Becker 1984; Jehu, 1988; Westerlund 1992).
Orgasm dysfunction is classified as a delay or absence of orgasm following normal sexual excitement (including subjective sense of sexual pleasure and physiological changes) which causes marked distress. Women experiencing orgasm dysfunctions, who have experienced sexual abuse, ranged between 18% and 45% (Becker, Skinner, Abel, Axelrod, Cichon 1984; Jackson, Calhoun, Amick, Maddever, Habif, 1990; Jehu 1988; Sarwer & Durlack, 1996; Westerlund, 1992). In a study of women with a history of inter-familial CSA, 56% reported feeling guilty about becoming sexually aroused, thus although some women may not have difficulties experiencing sexual arousal, the response to the sexual arousal may be upsetting (Westerlund 1992). In the long run, an emotional response of self-blame and guilt can have serious consequences for a survivor’s consensual romantic relationship.
These rates of sexual problems are higher than what we observe in the population at large, leading us to believe that sexual abuse survivors are at higher risk for developing sexual dysfunction than women with no history of abuse. For example, in a landmark study on the frequency of sexual dysfunction in women, Laumann et al. (1999) estimated that in women without a history of sexual abuse 22% experienced dysfunctions with desire, 14% with arousal, and 27% with reaching orgasm.
Why are women with a history of sexual abuse more at risk for experiencing sexual dysfunction? Although researchers have not identified one clear answer evidence points to a number of potential explanations.
Researchers have yet to determine how sexual abuse affects sexual arousal later in life. One theory is women who were abused during childhood have an altered sexual self schema, which inhibits sexual arousal (Meston, Rellini & Heiman, 2006). A sexual self schema is the way in which a person views themselves as a sexual being. If one has more negative attitudes, responses, and behaviors and fewer positive reactions to their sexual self, these thoughts and behaviors can interfere with positive sexual encounters (Andersen and Cyranowski, 1994). Moreover these intrusive thoughts may further lead to depression and anxiety; both disorders are linked with sexual dysfunctions.
Women who have experienced sexual abuse tend to also report higher rates of a variety of psychological disorders which may themselves affect sexual function.. These disorders include posttraumatic stress disorder, major depressive disorder, and a variety of anxiety disorders (i.e., panic disorder, social phobia etc). These psychological disorders are also more commonly associated with sexual dysfunction. For example, women with social phobia are also more at risk for female orgasmic disorder (Figueira, Possidente, Marques, & Hayes, 2001) and panic disorder has been associated with sexual aversion disorder and hypoactive sexual desire disorder (Figueira, Possidente, Marques, & Hayes, 2001). Thus it is feasible that the sexual difficulties of CSA survivors may be an indirect effect of the psychopathology they have developed after the abuse. Survivors often struggle with the effects of negative feelings resulting from the abuse. The combination of sexual dysfunctions, psychological disorders, and negative affect can have a serious impact on survivors’ romantic relationships.
Among the different types of psychopathologies experienced by sexual abuse survivors, PTSD is certainly the most common and the most studied one (Rowan, Foy, Rodriguez, & Ryan 1994). Symptoms of PTSD include vivid memories or flashbacks of the abuse accompanied with increased physiological arousal (heart rate, sweat gland activity, blood pressure) and avoidance of stimuli associated with the trauma (things that remind the survivor of the abuse, such as the place where the abuse occurred) (DSM IV-TR, APA 2002). The severity of PTSD symptoms is often associated with the severity of abuse (age at initial abuse, whether penetration occurred, and greater familiarity with perpetrator). The core aspect of PTSD is the involuntary re-experiencing of the trauma. Cues in the environment that can be as general as a light hitting the wall at a specific time of the day can trigger the emotional, cognitive and physiological responses that occurred during the abuse. People with PTSD may experience high levels of anxiety in response to a cue that may or may not be obvious. Individuals who experienced sexual abuse may be particularly sensitive to cues associated with sexual activities and this could lead to intense negative affectivity and/or flashbacks during sex, which would lead to an array of sexual dysfunction, including the tendency to avoid future sexual activities.
One study reported 64% of women with adult onset depression had experienced sexual abuse in childhood (Weiss, Longhurst, & Mazure 1999). Indeed, women with severe sexual abuse are ten times more likely to suffer from major depression with a lifelong diagnosis (Walker et al 1992). Like most disorders linked with CSA, the severity, duration, and age of onset of abuse increase the likelihood of developing depression. Moreover, the severity of abuse has also been associated with the likelihood to experience depression; Bifulco et al. found the incidence of depression to be 100% in women who suffered forced intercourse, 78% in those with repeated abuse not involving intercourse, and 30% in those with a single episode of abuse not involving intercourse (1991).
One of the most common symptoms of individuals with major depression is a loss of interest in sexual activities. The lack of sexual desire may be explained by impairments in the serotonergic system. Serotonin is a neurotransmitter involved in mood and motivation, low levels of serotonin are linked with lower sexual function, and is highlighted in the occurrence of sexual dysfunction after beginning SSRI treatment. Indeed, individuals who take SSRIs (i.e., Zoloft, Prozac, etc.) to treat depression often report a loss of sexual desire, which returns to regular levels after the patient stops the antidepressant medication. Recent studies have identified the serotonergic system as a key system involved in sexual desire. Thus, to the extent that many women with a history of CSA develop major depressive disorder, it is feasible that their lack of sexual desire and inability to become sexually aroused may be linked to their impaired serotonergic activity.
In women diagnosed with an anxiety disorder, there is a large sub population that has experienced sexual abuse; 45% of women with an anxiety disorder experienced sexual abuse compared to 15% without a diagnosed anxiety disorder (Stein et. al, 1996). Studies differ on which anxiety disorder is most associated with sexual abuse, but panic disorder, obsessive compulsive disorder (OCD), social phobia, and general anxiety disorder (GAD) are all prevalent. In a study of men and women with a history of childhood abuse, it was found that 28% developed panic disorder, 24% GAD, & 7% developed social phobia (Safren, Gershuny, Otto, Marzo, & Pollack, 2002). Of 149 participants who were diagnosed with both major depression and an anxiety disorder, 40% of participants were survivors of childhood abuse (Safren, Gershuny, Otto, Marzo, & Pollack, 2002).
Anxiety disorders can impact sexual function independently from a history of abuse. Researcher David H. Barlow has developed a model of how negative affect and hypersensitivity to sexual cues can feed into sexual dysfunction (Barlow, 1986). Anticipating a negative sexual performance increases one’s attention to the thought of not performing well. Because one is so focused on these thoughts, attention is directed away from sexually arousing stimuli and the positive sensations brought by these stimuli. Distracting thoughts such as “I am not good enough” may further increase autonomic arousal (increase heart rate, sweat gland production, etc.) and hyper-sensitivity to these bodily sensations can further interfere with sexual function. This model suggests that, for people who tend to be sensitive to anxiety, it may be particularly difficult to stop worrying about the consequences of not “performing” well and this can in fact have a negative impact on the sexual experience. In turn, this perceived lack of control in sexual performance also interferes with expectations for future sexual experiences. To avoid the negative feelings and consequences of a dissatisfying sexual experience, one may start avoiding sex entirely. However, avoidance has the paradoxical effect of increasing anxiety related to the avoided activity.
Women with a history of sexual abuse tend to report lower satisfaction in romantic relationships than women without such history (DiLillo & Long, 1999). Some researchers attribute satisfaction and quality of relationships to the effects of the early abuse on the ability of the individual to develop strong and healthy attachment with their caregivers. Attachment theory suggests that individuals learn to create meaningful interpersonal relationships at a very young age, as they bond to their caregivers. Indeed, these theorists would argue that much about the way in which people relate to others, regulate emotions, cope with anxiety and stressors can be traced back to important lessons learned during the first years of life. Research has indeed found a relationship between many psychopathologies in adulthood and the way in which people related to their caregivers as young children. Preliminary studies have also provided initial evidence that the way in which an individual processes emotion, expresses affection and communicates with a partner is explained by the different types of attachment styles (Johnson 2004). Although these attachment styles are formed early on, they can be modified by subsequent experiences. A child sexually abused at a young age may develop dysfunctional attachment styles. Trusting others and believing that the world is an overall safe environment are some of the beliefs that may be shattered by the abusive experience and this may lead to a different attachment style (Davis & Petretic-Jackson, 2000). Consequentially, the ability of this individual to trust an intimate partner may be negatively affected and to the extent that sexual activities require the individual to open up and trust the sexual partner, people who fear intimacy may also develop difficulties in their sexual function. Indeed, many women with a history of sexual abuse will report that it is hard to “let go” during sexual activities because letting go mean trusting the partner. While the woman may trust her partner she may not be able to experience this trust during a state of vulnerability. These worries about protecting one’s self and not fully trusting another can undoubtedly interfere with the ability to become sexually aroused and to have an orgasm.
Very little is known on the physiological and psychological treatment for sexual dysfunction in women, in general, and even less is known on the treatment of sexual dysfunction in women with a history of sexual abuse. Sildenafil, better known as Viagra, was used to treat 35 women suffering from sexual arousal disorder (Basson, McInnes, Smith, Hodgson, & Koppiker, 2002). Of the 35 participants, 7 women had a history of CSA. Women without a CSA history reported better vaginal lubrication (51%), improved sensation in the genitals (77%), described intercourse/foreplay to be pleasant & satisfying (58%), and 68% reported reaching orgasm was easier after treatment of sildenafil. Women with a history of CSA reported better vaginal lubrication (29%), improved sensation in the genitals (29%), described intercourse/foreplay to be pleasant & satisfying (14%), and 29% reported reaching orgasm was easier after treatment of sildenafil (Berman et al., 2001). However, CSA survivors also reported greater distress experienced in response to the increased vaginal engorgement during exposure to sexual stimuli. This distress was not noted in participants who did not have a history of abuse. It is feasible that a greater concordance between physiological and subjective sexual response may be a more appropriate outcome than just an increase in genital responses. Therefore, sildenafil and other medications that promote the selective increase in vasoengorgement are not recommended for the treatment of sexual dysfunction of CSA survivors. Most therapist would agree that treatment for women with a history of sexual abuse should focus more on aligning the subjective and physiological arousal, rather than concentrating on increasing exclusively physiological sexual arousal.
Non-pharmaceutical treatments offer some advantages to pills because of the lack of adverse side effects and perceived concept of self control. Mindfulness is an example of a recently tested treatment for sexual dysfunction. Mindfulness is an eastern practice of wakefulness and non-judgmental present moment awareness closely tied with meditation (Baer, 2003). Mindfulness, which promotes self regulation, is helpful in reducing anxiety patients’ symptoms and has shown remarkable post-treatment effects, with improvements in anxiety persisting for up to three years after the initial treatment (Baer 2003). Patients with major depressive disorder also benefited in the short and long term with mindfulness therapies. A mindfulness approach therapy has recently been tested by Dr. Lori Brotto and colleagues seem to have found this approach to be particularly useful with CSA survivors. In a study among 25 women (17 women with no history of abuse and 8 women reporting a history of sexual abuse) mindfulness combined with cognitive behavioral approaches was found to significantly improve sexual function. In this study, survivors of sexual abuse improved more than the women with no history of sexual abuse on all three outcome measures: sexual arousal, sexual dysfunction, and sexual distress (Brotto, Basson, & Luria, 2008).
The presence of comorbidity of personality disorders, relational problems, and physical sexual dysfunctions makes choosing an appropriate route of therapy difficult. Clinicians struggle with deciding which issues to focus on during treatment since many of these issues have direct associations with one another (i.e. effect of depression on sexual dysfunction). No firm data show if it is more beneficial for sexual dysfunction to treat the psychological issues that accompany the dysfunction or the dysfunction itself first. Most psychotherapists will treat PTSD, anxiety, depression, etc. as a primary issue and a sexual dysfunction as an associated disorder of the primary diagnosis. Sex therapy generally uses a sensate approach or something similar to help the individual focus on sensation versus sexual performance by using a hierarchal system allowing a couple to start slowly at a caress or a kiss and work their way up to intercourse (Wincze & Carey, 1991). Stimulus control is also a popular approach. Stimulus control establishes a positive environment to enjoy sexual activity; in the case of sexual abuse, focusing specifically on removing all items in the area that may remind the survivor of the abuse environment can improve their enjoyment of sex (Wincze & Carey, 1991). Lastly, sex therapists work with survivors to adjust their negative affect. It is important for both partners to address their negative feelings so there can be a complete therapeutic intervention.