SEXUALLY ABUSED KIDS
Last week I published a tongue-in-cheek response to an op-ed I had read in the editorial page of our local newspaper. The admonishment of the writer of the op ed that we should limit our talk about childhood sexual abuse stirred up some painful memories for me of patients who were attempting to overcome the effects of childhood sexual abuse.

A True Story
One case in particular comes to mind. This patient was an attractive young woman who came to see me with vague complaints and reported she had come because: “I just want something for my nerves.” After initial hesitation, she was able to give a more detailed history. Her general presentation confirmed my initial impression that she was suffering from clinical depression. She seemed shy and avoided eye contact until I asked if she worked, at which time she looked directly at me as if to assess my response as she hesitantly told me she worked as an “exotic dancer.” Apparently, I passed the test, for at that point, she unloaded in great detail how she had chosen such a career, and how she hated it.
She grew up in a blue collar family. Her father was a factory worker who forbade his wife from working. Her dad was a periodic, episodic alcoholic, and when drunk, was violent and abusive. When sober he was easily provoked. Mother was cowed, totally submissive, and seemingly helpless to protect her children from her husband’s rages. My patient (we shall call her Mary) along with her two older brothers developed strategies to avoid Dad when he was expected to come home drunk. As Mary grew into adolescence, her father began to take notice of her, and finally on the return from one of his nightly drunken forays came into her room and raped her.

But this was not the end of the abuse for the old man had the temerity to excuse his behavior by telling Mary that it was only because he loved her that he was sexually attracted to her. She accepted his advances as she was terrified at the thought of his beating her as he periodically did her mother.

Think it couldn’t get any worse?
Think it could’t get worse than this? Wrong. Soon her brothers emulated their father and to make matters even more unbearable bragged about having sex with her to their friends at school. As you might expect, this led to pursuit by many of the boys at school who were convinced that she was an “easy lay.” And where was Mary’s mother while this was going on? Mary was convinced she was aware, and attempted to convince herself that mother was so beaten down as to be rendered helpless, but she was also horrified to think that her own mother might have offered Mary up to her father in order that she would not be a target of his rages.
Emotional Extortion
Mary’s father had promised all kinds of dire consequences if Mary should ever breathe a word to any one about his behaviors. She knew that she would get no support from her mother were she to seek outside help. By now, even Mary’s teachers were convinced that she had become a problem as they heard that she was promiscuous. There was a reluctance to tell anyone due to the intense feelings of shame she felt about the incestuous relationships. There was also that long held custom of blaming the female in such situations, of which Mary undoubtedly was well aware.

The Spiral
The effect of all these prohibitions was made evident as she several times during the session asked for reassurance of confidentiality. In such a situation, the only sensible thing for her to do was run away, which is what she did. From then until the time of our session, her chronology was a bit hazy. I suspect that some pimp thought he had struck it rich when he discovered this beautiful little runaway. Although she did not admit to such, it seems likely she did engage in prostitution. In any event, at this point I felt it not necessary to probe deeper into her past for I had already seen enough pain to last for the rest of the day. It is enough to say that somewhere along the line she did find a way to use the only tool available for her to make a living in a semi-legitimate manner by swinging around a pole naked. Unfortunately, I never saw her again but noted the “men’s club” where she had been working was closed down by the sheriff. Her name was not listed among those who were arrested.

Sex abuse survivors suffer long after the abuse ends 
You may be thinking stories of this kind unusual, but they are not rare. It has been several years since that day I saw Mary, but I still think of her occasionally and wonder what her life is like now. I hope she found a good guy to marry has a couple of kids and is living happily ever after. But in my heart of hearts I know that is very unlikely. Those who have suffered such abuse usually have serious trust issues which interfere with the formation of meaningful relationships. Even though they know on a rational level that the abuse they suffered was not their fault, they often blame themselves by questioning whether the assault was brought on by their seductiveness, which is reinforced by the oft heard “she must have done something to bring this on.” They lack self-esteem, devalue themselves, and feel unworthy. When shown attention, they may be suspicious and distance themselves while others may become promiscuous, feeling they have nothing to offer other than sex. In their search for love, they find themselves in a series of abusive relationships a la the repetition compulsion which Freud so eloquently described.
Meanwhile, I continue to fuss over the op ed that I sarcastically commented on in my most recent blog. I was curious when I first saw the title of Ms. Flowers piece, but as I read on I became so angry that I could have had a Lindsey Graham type temper tantrum on the spot. I immediately wrote a rebuttal in my passive aggressive style, which Maggie thought was worthy of publication however; I feel the subject of child abuse deserves something more than a few smart-ass comments. I felt that Mary’s story speaks eloquently as to the effects of childhood sexual abuse. Fortunately, most cases are not so horrifying as hers, yet even less aggressive acts can have long lasting effects.

More light required
Yes, I was angry with the writer for her blame the victim tactic, and her concern about Kavanaugh’s “pain” but not one kind word about Dr. Ford. But the clincher for me was closing statement in Ms. Flower’s op ed in which she writes: “That we have now reached the point that assaulted children are considered appropriate conversational tender sterilizes the soul and induces a nausea that can’t be eliminated…”I submit that such an attitude is a major contributor to child abuse. For too many years as with Mary, most such vile acts which have robbed many children of their innocence often leaving them significantly impaired with a lifetime of suffering have been carried out in secret.
There has been some progress in shining the light on the problem e.g. there are now mandatory reporting laws in most states which require physicians, nurses, social workers, emergency rooms, psychologists, etc., to report their suspicions that a child is being abused, and yes that includes the sexual abuse which Ms. Flowers insists should not be a subject of “civil discourse.” It is also encouraging that many charged with caring and working with kids are being prosecuted, and that the veil of secrecy that has surrounded the violation of children by priests is being lifted. However, the National Center for Victims of Crime reports some very disturbing statistics which confirm sexual abuse of children remains a serious problem:

• 1 in 5 girls and 1 in 20 boys is a victim of child sexual abuse;
• Self-report studies show that 20% of adult females and 5-10% of adult males recall a childhood sexual assault or sexual abuse incident;
• During a one-year period in the U.S., 16% of youth ages 14 to 17 had been sexually victimized;
• Over the course of their lifetime, 28% of U.S. youth ages 14 to 17 had been sexually victimized;
• Children are most vulnerable between the ages of 7 and 13.
• 75% are abused by people they know and often those whom they trust
• 23% of reported cases are perpetrated by kids under the age of 18
• 40 to 80% of such juvenile offenders have themselves been victims

As we have witnessed in that infamous recent Supreme Court hearing, many of the old habits which allowed such awful acts to be inflicted on our children are still in place. The issue must not be swept under the rug as Ms. Flowers suggests but should be considered “civil discourse” of the highest order. Pedophiles do not feature a sign on their foreheads announcing their sexual proclivities therefore; those to whom we entrust our children deserve careful scrutiny. My own experience in that regard accentuates that truth.

Wolf in Sheep’s Clothing
He was a person for whom I had a great deal of respect. We first met when I was a psychiatry resident, and I was impressed with his knowledge and competence as a board-certified child psychiatrist with many years of experience in institutional practice with a University affiliation.

Upon completion of my residency, he invited me and a couple of other recent graduates to join him and form a group practice. Fortunately for me, I received another offer for later I was shocked to find he was sentenced to a lengthy prison term for child sexual abuse. He had apparently managed to abuse children, in most cases, who were residing in institutions, where complaints would likely be ignored. Of course, no one knows how many lives he may have ruined. In retrospect I realized I had missed all the warning signs.
Yes, it is my most ardent belief that the problem of childhood sexual abuse deserves serious attention and more “civil discourse” not less of it.