The Future of Children, Princeton - Brookings: Providing research and analysis to promote effective policies and programs for children.

Avoidant behavior among victims of sexual abuse may be understood as attempts to cope with the chronic trauma and dysphoria induced by childhood victimization. Among the dysfunctional activities associated with avoidance of abuse-specific memories and feeling are dissociation, substance abuse, suicidality, and various tension-reducing activities.⁹ In each instance, the problem behavior may represent a conscious or unconscious choice to be involved in seemingly dysfunctional and/or self-destructive behaviors rather than fully experience the considerable pain of abuse-specific awareness. Unfortunately, although sometimes immediately effective in reducing distress, avoidance and self-destructive methods of coping with child abuse experiences may lead ultimately to higher levels of symptomatology, lower self-esteem, and greater feelings of guilt and anger.⁴⁹

Dissociation can be defined as a disruption in the normally occurring linkages between subjective awareness, feelings, thoughts, behavior, and memories, consciously or unconsciously invoked to reduce psychological distress.⁹ Examples of dissociation include: (1) derealization and depersonalization, that is, the experience of self or the environment as suddenly strange or unreal; (2) periods of disengagement from the immediate environment during times of stress, for example, via "spacing out" or excessive daydreaming; (3) alterations in bodily perception; (4) emotional numbing; (5) out-of-body experiences; (6) amnesia for painful abuse-related memories; and (7) multiple personality disorder.⁵⁰ Dissociative symptomatology has been linked to sexual trauma in children^5,51 and adults.⁵² Such symptoms are apt to be prevalent among child and adult survivors because they reduce or circumvent the emotional pain associated with abuse-related experiences or recollections, permitting superficially higher levels of psychological functioning.⁵³

Dissociation is thought to underlie many individuals' reports of periods of amnesia for their childhood abuse in that such memories are believed to have been defensively excluded from conscious awareness.⁵⁴ Two studies suggest that adults in psychotherapy quite commonly report some period in their lives when they had incomplete or absent memories of their childhood abuse. Herman and Schatzow found that 64% of 53 women undergoing group therapy for sexual abuse trauma had some period of time prior to treatment when they had incomplete or absent memories of their molestation.⁵⁵ Among 450 men and women in psychotherapy to deal with abuse-related difficulties, 59% reported having had some period before age 18 when they had no memory of being abused.⁵⁶ In both of these studies, self-reported abuse-related amnesia was associated with more severe and extensive abuse that occurred at a relatively earlier age. Loftus, Polonsky, and Fullilove found that 19% of more than 50 sexual abuse survivors in treatment for chemical dependency stated that, at some point in the past, they had no sexual abuse memories and that an additional 12% had only partial memories of their childhood sexual victimization.⁵⁷ Interestingly, in the latter study, the authors interpreted their data as not necessarily supporting the notion of psychogenic amnesia, per se, but rather referred to this process, at least in some instances, as "forgetting."

In a methodological improvement over the above retrospective studies, Williams followed up 129 women who, as children, had been seen in an urban emergency room with a primary complaint of having been sexually abused.⁵⁸ These subjects were interviewed approximately 18 to 20 years later—without knowledge that the interviewers were aware of their childhood ER visit—and asked whether they had ever been sexually abused as children. Thirty-eight percent of this sample reported no memory of having been sexually abused, despite records that sexual abuse had, in fact, taken place. Unlike previous investigations, this new study cannot be faulted in terms of potential biases to recall, because the original abuse had been verified and the subjects were currently denying (as opposed to alleging) a sexual abuse history. Assuming that their nonreport was not caused by inhibition, modesty, or other conscious influences (a doubtful explanation because many reported other painful or upsetting childhood events, including other sexual abuse experiences), Williams's subjects appear to provide data that childhood abuse experiences can, in fact, be excluded from current memory.⁵⁹

A number of studies have found a relationship between sexual abuse and later substance abuse among adolescent⁶⁰ and adult survivors.⁶¹ Briere and Runtz report that sexually abused female crisis center clients had ten times the likelihood of a drug addiction history and two times the likelihood of alcoholism relative to a group of nonabused female clients.⁶² It seems likely that sustained drug or alcohol abuse allows the abuse survivor to separate psychologically from the environment, anesthetize painful internal states, and blur distressing memories. Thus, some significant proportion of those currently addicted to drugs or alcohol may be attempting to self-medicate severe abuse-related depression, anxiety, or posttraumatic stress. From this perspective, treatment or forensic interventions that merely detoxify and/or punish substance abuse are unlikely to be effective—especially in the longer term. Instead, addicted survivors may respond more definitively to therapeutic or self-help interventions that reduce the abuse-related internal distress motivating chemical dependency.

The ultimate avoidance strategy may be suicide. As noted by Schneidman, Farberow, and Litman, escape from extreme psychic pain—that is, depression, anxiety, or extreme hopelessness—is a commonly expressed motivation for suicide. ⁶³ Thus, it should not be surprising that increased suicidal ideation and behaviors have been linked to sexual abuse in child victims.^27,64 Similarly, several studies of adults who were molested as children document more frequent suicidal behavior and/or greater suicidal ideation among survivors relative to their nonabused peers. Rates of a previous suicide attempt, for example, were 51% in a subsample of 67 sexually abused female crisis clients⁶⁵ and 66% in a subgroup of 50 sexually abused female psychiatric emergency room patients,⁶⁶ as compared with an average rate of 27% for nonabused patients in these studies. In a community sample, approximately 16% of survivors had attempted suicide, whereas fewer than 6% of their nonabused cohorts had made a similar attempt.³²

Certain behaviors reported by adult survivors of child sexual abuse, such as compulsive and indiscriminate sexual activity, bingeing or chronic overeating, and self-mutilation, can be seen as fulfilling a need to reduce the considerable painful affect that can accompany unresolved sexual abuse trauma. Often these activities are seen as "acting-out," "impulsivity," or, most recently, as arising from "addictions." For the abuse survivor, however, such behaviors may best be understood as problem-solving behaviors in the face of extreme abuse-related dysphoria.

Chronic abuse-related distress may be reduced by activities that provide temporary distraction, interrupt dysphoric states, anesthetize psychic pain, restore a sense of control, temporarily "fill" perceived emptiness, and/or relieve guilt or self-hatred.⁹ These behaviors are frequently effective in creating a temporary sense of calm and relief, at least for some period of time. Ultimately, the use of tension-reducing mechanisms in the future is reinforced through a process of avoidance learning: behavior that reduces pain is likely to be repeated in the presence of future pain.

Indiscriminate Sexual Behavior

It is widely noted by clinicians that adolescents and adults molested as children are prone to episodes of frequent, short-term sexual activity, often with a number of different sexual partners.^34,67 This may explain why, compared with their nonabused peers, survivors of sexual abuse are at greater risk for unintended and terminated pregnancies, as well as for contracting sexually transmitted diseases.⁶⁸

In addition to temporarily addressing the need for closeness and intimacy- arising from deprivation in these areas during childhood—indiscriminate sexual behavior by some sexual abuse survivors may provide distraction and avoidance of distress for some adults molested as children. Sexual arousal and positive sexual attention can temporarily mask or dispel chronic abuse-related emotional pain by providing more pleasurable or distress-incompatible experiences. For such individuals, frequent sexual activity may represent a consciously or unconsciously chosen coping mechanism, invoked specifically to control painful internal experience.

Bingeing and Purging

Specialists in eating disorders have suggested recently that both adolescent and adults with bulimia (episodes of bingeing on food, then purging via vomiting or laxatives) may be especially likely to report child sexual abuse histories.⁶⁹ Although this is a relatively new area of research related to sexual abuse, it appears that childhood molestation is associated specifically with bulimic bingeing and purging, whereas (nonbingeing) anorexia nervosa is less relevant to sexual molestation history, per se.⁷⁰ It should be noted, however, that at least one review of the literature questions the validity of a sexual abuse-bulimia relationship.⁷¹ Root and Fallon suggest that binge-purge behaviors can operate as "both a reaction to and a method of coping with physical and sexual abuse."⁷² The tension-reducing aspects of bulimia include self-soothing, distraction from non-food-related concerns, and a (literal) filling of perceived emptiness.

Selt-Mutilation

Self-mutilation is defined by Walsh and Rosen as "deliberate, non-life-threatening, self-effected bodily harm or disfigurement of a socially unacceptable nature."⁷³ It most typically involves repetitious cutting or carving of the body or limbs, burning of the skin with cigarettes, or hitting of the head or body against or with objects.⁷⁴ Each of these forms of self-injury has been found to occur among recent or former victims of child sexual abuse.^74,75 Various authors have hypothesized that self-mutilatory behavior serves to temporarily reduce the psychic tension associated with extremely negative affect, guilt, intense depersonalization, feelings of helplessness, and/or painfully fragmented thought processes—states all too common among survivors of severe sexual abuse.⁷⁶ Although often immediately effective, such behavior is rarely adaptive in the long term, leading to repeated cycles of self-injury, subsequent calm, the slow building of further tension, and, ultimately, further self-mutilation.