60 20th annual crime prevention guide Excerpt from Handbook of Sensitive Practice for Health Care Practitioners Lessons from Adult Survivors of Childhood Sexual Abuse respond to childhood sexual abuse. Some of these include the gender of the perpetrator, the number of perpetrators, the nature and closeness of the relationship between victim and perpetrator, the duration and frequency of the abuse, characteristics of the abuse itself (e.g., contact vs. noncontact, penetration, etc.), the use of threats or force, and the age of the victim at the time of the abuse. Childhood sexual abuse and health While not everyone who reports a history of childhood sexual abuse develops health problems, many live with a variety of chronic physical, behavioural, and psychological problems that bring them into frequent contact with health care practitioners. Because health care practitioners do not routinely inquire about childhood sexual abuse, its long-term effects are under recognized, its related health problems are misdiagnosed,and it is often not met with a sensitive, integrated treatment response. Childhood sexual abuse often co-occurs with other types of childhood adversity, including physical abuse, marital discord, separation from or loss of parents, parental psychopathology and/or substance abuse, and other types of abuse/neglect. Even when these other types of adversity are controlled for, childhood sexual abuse remains a powerful predictor of health problems in adulthood. It is suggested that the underlying mechanism for these difficulties is “that childhood sexual abuse causes disruptions in the child’s sense of self, leading to difficulty in relating to others, inability to regulate reactions to stressful events, and other interpersonal and emotional challenges”. Kathleen Kendall- Tackett describes behavioural, emotional, social, and cognitive pathways by which childhood abuse affects health, pointing out that “adult survivors can be affected by any or all of these, and the four types influence each other. Indeed, they form a complex matrix of interrelationships, all of which influence health.” In addition, research in the fields of immunology, endocrinology, and psychosomatic medicine has demonstrated clear physiological relationships among stress, illness, and disease. Table 1 lists the findings of a number of studies that have examined the correlation between histories of childhood sexual abuse and later health and function. Considerably more studies have examined these relationships in women, and when male survivors have been studied, the relationship between past abuse and the mental health of male survivors has been the primary focus. Guy Holmes, Liz Offen, and Glenn Waller argue that two pervasive myths – that males are rarely sexually abused and that childhood sexual abuse has little effect on males – deter boys and men from disclosing their abuse and, in turn, prevent society from legitimizing it as a problem. The increasing societal recognition of the prevalence and seriousness of sexual abuse of boys is likely to lead to further investigation of physical health correlates. Public Health Agency of Canada continued... ...Handbook on Sensitive Practice continued Two pervasive myths (that males are rarely sexually abused and that childhood sexual abuse has little effect on males) deter boys and men from disclosing their abuse and, in turn, prevent society from legitimizing it as a problem. TABLE 1 Correlates of childhood sexual abuse and measures of health and function: A selected list of findings from research studies In females, a history of childhood sexual abuse or a range of childhood traumas including sexual abuse is correlated with: • poorer physical and mental health and a lower health-related quality of life than non-traumatized individuals • chronic pelvic pain • gastrointestinal disorders • intractable low back pain • chronic headache • greater functional disability, more physical symptoms, more physician-coded diagnoses, and more health risk behaviours, including driving while intoxicated, unsafe sex, and obesity • ischemic heart disease, cancer, chronic lung disease, skeletal fractures, and liver disease • high levels of dental fear • greater use of medical services • drug and alcohol use, self-mutilation, suicide, and disordered eating • adult onset of 14 mood, anxiety, and substance use disorders • higher rates of childhood mental disorders, personality disorders, anxiety disorders, and major affective disorders, but not schizophrenia • diagnosis of Borderline Personality Disorder