The challenge of treating survivors of childhood sexual abuse

Chris Hogan

28/06/2018 2:39:05 PM

Dr Chris Hogan reflects on his experiences with adult survivors of childhood sexual abuse.

Dr Hogan said he is careful to never to openly ask about childhood sexual abuse, but rather approach the subject cautiously.
Dr Hogan said he is careful to never to openly ask about childhood sexual abuse, but rather approach the subject cautiously.

A teacher at medical school once told me that the whole world will walk through your room in general practice. It’s true.
We see people at their best and worst.
And, I believe, we also see good and evil. The worst I have ever dealt with is childhood sexual abuse.
When my first patient revealed her history, I was ready. As a registrar I did a superb rotation in psychiatry, which prepared me for my future in general practice. In that rotation, I was taught childhood sexual abuse was too common, too nasty and too often missed. I took that to heart.
One day, a patient asked me if the reason she did not enjoy sex might be linked to a childhood sexual abuse.
She was scared, and she had been damaged by the assault. But she was the first of many who showed me that the greatest courage is displayed by those who fight to live a normal life.
After more and more patients told me their stories, I started to recognise the pattern of behaviour common to these troubled adults. They were desperate to be listened to, but afraid to speak. Why?
They had an uncomfortable relationship with authority figures, based on who their abusers were, and they considered doctors to be authority figures. Desperate for help, but terrified they would be rejected, disbelieved or, worst of all, exploited again.
Some presented an aggressive front, others defensive. Many kept coming to see me with an anxiety that far exceeded their trivial presenting complaint.
But how to broach such a difficult, painful topic?
I was taught never to openly ask about childhood sexual abuse and I found that was excellent advice. For many survivors, the topic had to be raised very cautiously.
My suspicions are first raised whenever an adult patient presents to me with one or more of these symptoms:

  • Recurrent trivial issues accompanied with disproportionate anxiety, or a sense of being heartsick
  • Sexual dysfunction, especially anorgasmia
  • Overprotective of their children
  • A powerful resistance to ‘bringing children into this terrible world’
  • Chronic non-specific pain
  • Insomnia
  • Drug dependency (especially benzodiazepines or other agents that block dreams)
Whenever a patient like this comes to me, I listen and wait, support and offer what I can: comfort, simple suggestions and structure. I have learnt to wait for the time when they trust me enough. When I judge that the time is right, I ask something like:
‘Is there anything old or new bothering you? Something that you have not yet mentioned?’
I then pause for a long time, to see if they are willing to discuss it. Sometimes, I’ve got it wrong and there was no childhood sexual abuse. But other times, I would hear it all.
Over the years, more and more adults revealed their suffering and named their pain, and gave voice to the terrible details of their distress. I came to recognise that their abuse – and the techniques used by their abusers – was so consistent that, even in the pre-internet days, their abusers had to be in communication with each other.
Worse, these abusers had laid a booby trap for any therapist or healthcare professional attuned enough to recognise the signs of childhood sexual abuse, but not experienced enough to be cautious.
The trap is this: confidence has often been destroyed by their abuser. They may have been told they are shameful, chosen because they are weak or different, or even evil.
For these people, asking too quickly if they are survivors of childhood sexual abuse can actually confirm in their minds this pernicious thought planted by the abuser. That they are different, or evil. For these patients, asking too soon may cause them to shut down entirely. They will then reject further offers of help, or even be driven to despair.
I have very rarely seen children who were actively being abused. I knew what cluster of symptoms to look for – a previously happy child with a sudden deterioration in school performance, flares in aggression, inappropriate sexual behaviour or language, self-harm and a significant risk of depression. There would be loss of urinary or faecal continence and either excessive washing and attention to personal hygiene, or the loss of all hygiene.
It took a while before I found a trusted group of colleagues with whom I could safely discuss my suspicions. When they – and I – agreed that there was real cause for concern, I would refer children discreetly to the children’s hospital for assessment.
A mother brought her eight-year-old to me, concerned about why she was compulsively washing her private parts; a seven-year-old who was irritable, angry and no longer toilet trained; a 13-year-old who became depressed, angry and prone to truancy after previously being an excellent student.
But if I look back, most of the people I treated were adults, who had been suffering in silence for many years.  
When these survivors decided that I was safe to trust with their story, I would listen.
Then I would ask if the abuser were still alive and explain their options, including the role of organisations like the Centres Against Sexual Assault. I would offer referrals to psychologists and psychiatrists.  
Often it helped. But not always.

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Dr Jan Sheringham   30/06/2018 9:36:40 AM

Very well described and beautifully written Chris - your experiences almost mirror my own, except for the experience in my Psych term and my decision, on many occasions, to carefully ask about the possibility of “had anyone hurt or touched you in the past when you were young, or against your wishes? Because I see many parallels in your story over the times we have spoken to others who have suffered in these ways.” Perhaps the subject is easier for females to broach where the perpetrators are mostly male, but the really hard nuts were those where there was the collusion of disbelief by the relevant parent, usually Mum! Please keep spreading the word, and handing on your knowledge - it is so valuable for all of us, young or old.

Naz   7/07/2018 10:15:07 PM

Excellent article... reflects my experience. Agreed , the approach of a female GP is prob different to that of a male. Agreed , timing is very important.... you can cause a shut down and lose the patient if she is not ready to talk. Listen....and you will hear. When you scratch your head in confusion.... ask could this be..... Be aware. It is almost epidemic.
And above all, look after yourself. It can be very confronting and distressing at may need support and an opportunity to debrief.