Child sexual abuse : Disclosure, social support and subjective health in adulthood

Child sexual abuse (CSA) is a known risk factor for ill-health. It is assumed that the health consequences are worse if the abuse has been considered severe or if the child has been exposed to cumulative trauma, e.g. physical abuse or other stressful life events. However, symptom development seems to vary widely between individuals. According to developmental theories the dynamic interplay between environmental and individual conditions creates a course toward either healthy or maladaptive outcomes. Social support has been shown to have a strong influence, direct or indirect, on abuse sequelae - a higher amount of support is related to better psychological functioning. However, adult victims may have difficulties forming close relationships with others due to lack of trust and other abuse aftermath. Further, despite a high risk for ill-health victims often fail to disclose the abuse. If they do tell they are not rarely met by negative reactions, which has been related to worse outcome. Delayed disclosure is related to intra-familial abuse, closeness to the perpetrator, multiple perpetrators, age at onset and severe abuse. The victim may experience a psychological disclosure dilemma: the need to tell in order to get support is weighed against the risk to receive negative reactions. Thus, the overall aim of the thesis was to contribute knowledge concerning the relationship between child sexual abuse, disclosure, social support, and subjective health in adult women reporting experiences of sexual child maltreatment. Methods. The thesis was based on a study with a cross-sectional design using retrospective data about abuse and disclosure experiences as well as current data about health and social support. Participants (n = 152, aged 20-60 years) were recruited by advertisements in a membership magazine published by a national organisation for sexually abused women providing activities for support and healing, as well as in staff magazines for municipal employees in the Stockholm area. Data was retrieved by both a semi-structured interview and questionnaires. Analyses included quantitative methods (variable-approach and person-approach) as well as qualitative methods. Results. The results showed that disclosure characteristics were more prominently related to health than sexual abuse characteristics. Moreover, in spite of experiences of severe abuse and negative reactions after disclosure it was possible to get access to health enhancing social support in adulthood. The relation between disclosure-related events and health was dependent on source and type of reaction, in favour of partner and friends. A positive reaction from a partner was strongly related to subjective health. It may be crucial for victims of CSA who have problems with trust and intimacy to get emotional support, acceptance and respect from a partner in overcoming these feelings. Further, two groups of women reporting good health in spite of severe abuse were found by cluster analysis. The groups were among other things characterised by a high proportion of women who had formerly been active members in the support organisation. A qualitative analysis of the member's experiences from the organisation showed that a victim process altering the victim identity over time seemed to constitute an important part of the individual development. However, few members who had gone through crucial steps of the victim process seemed to remain in the organisation passing the knowledge on to new members, thus creating a chronic structural problem for the organisation to deal with. Conclusions. Social support is a crucial protective factor for victims of child sexual abuse, a group highly at risk for and ill-health and adverse outcome. Victims of child sexual abuse seek and receive social support in various ways depending on severity of abuse, timing of disclosure and choice of disclosure receiver. Thus, the whole disclosure process during life is important to consider when studying disclosure-related events in relation to social support and health. Further, different methods of analyses may contribute to the understanding of how risk and protective factors interact. Both variable- and person-based methods pointed at the importance of resources like selfesteem and social support above the amount of risk factors for health outcome. Finding ways to combine self-help with professional help might be fruitful and constitutes a further challenge for psychiatry when it comes to the task of developing new and effective care for this group