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There has been an increasing awareness of institutional child sexual abuse (CSA) and a number of public inquiries into this problem.   The prevalence of child sexual abuse in the community depends on how it is defined but in men was 3% in a general practice and 18% in a genitourinary clinic.

The common general effects of child sexual abuse include sexualising effects with heightened sexual activities amongst females or inhibitory effects.  Boys who experience homosexual abuse may show confusion and anxiety over their sexual identity.  There is a sense of guilt expressed by victims that could have done more to stop abuse or they derived pleasure from the abuse.  They may experience a sense of powerlessness and isolation leading to difficulties in trusting.  Depression combined with anger is common with feelings of helplessness and hopelessness. There are frequently anxiety effects with fearfulness, somatic complaints, changes in sleep patterns and nightmares. These are associated with post-traumatic effects; flashbacks, re-enactments associated with reminders of the abuse, withdrawal from situations associated with abuse, startle reactions and hypervigilance.  The most common behavioural reaction described in boys is the development of aggressive behaviour such as bullying, chronic disobedience and anti-social acts.  There is an increased rate of prostitution in women.

The most common reason for entering care was anti-social behaviour and many of the children would have received a diagnosis of conduct disorder.  They were trapped within the institution in isolated locations making contact with families difficult.  The education was in internal schools.  The institution often controlled leaves, visits and privileges.  The social workers only visited occasionally and the children were generally unaware that others were being abused. Bullying was common and children abused within homes run by religious orders were subjected to emotional abuse by the threat of divine damnation. Those going into care lacked of trust in authority which was often compounded by their treatment emotionally, physically and sexually in the institutions and by not being believed when they complained. This resulted in more anti social behaviour.

The boys lacking good adult role models and father figures were ‘groomed’ by male staff,  then sexually abused but believed they were being loved. They were confused by this with feelings of guilt and were damaged in their ability to trust someone within a loving relationship. Their experiences led to an increase in violence as a way of resolving disputes and many victims have difficulty dealing with their own children in terms of physical intimacy.  There are cases of post traumatic stress disorder with typical features of nightmares, flashbacks, hyperarousal, associated anxiety and depression.  Some victims had PTSD whilst in care and for a period afterwards whilst others had PTSD triggered off by the birth of children or by the police investigation into these institutions.

These people often show marked antisocial behaviour in adult life and conduct disorder in childhood strongly associated with antisocial personality disorder in adults.  The experience of abuse led to a greater lack of respect and rebelliousness in this group.  There is evidence linking CSA and the increased risk of drugs and alcohol.

There is often a delay in disclosure of the abuse for many years.  It seems that some people become amnesic of abuse events but there is a normal process of suppression of distressing memories illustrated when disclosure leading to distress and sometimes secondary PTSD.

It is difficult to study causation of psychiatric illness as retrospective studies cannot prove causation.  Psychopathology and psychiatric illness is associated with sexual abuse that continued for a longer period, involved penetration, interfamilial abuse, greater age gap and aggression. There are increased rates of most psychiatric conditions: childhood mental disorders, mood disorders, eating disorders, personality disorders and post traumatic disorders. Studies of CSA being associated with the development of psychotic disorders and schizophrenia are less consistent in their findings.  The difficulty of assessing causation and quantum in these cases is that all children taken into care are at increased risk of poor psychological outcome even if not abused due to pre existing risk factors.

It is known that many adults should not have treatment and that counselling often increases symptoms.  It should not be offered routinely to victims of abuse.  In adults with severe symptoms then cognitive behaviour therapy and debriefing may be appropriate. There should be specific treatment of the illness including treating depressive illness with antidepressant medication and expert treatment for sexual dysfunction, alcohol and drug abuse, self harming behaviour and eating disorders by therapists with  expertise in child sexual abuse.

Dr Trevor Friedman, Psychiatrist