The first time it happened, Christine
Christine never saw the man again, but it was not the end of her experience with sexual trauma. She lived in a neighborhood with a high crime rate. She was a latchkey kid, who was often unsupervised and left to fend for herself. Sexual abuse seemed to follow her.
In high school, she was gang-raped at a party. Years later, after she joined the military, she met a man whom she thought she could trust. They dated for a short period, but just when she decided to end the relationship, he forced himself on her.
Now, at 38, Christine is finally in a solid, healthy relationship. But she still has her struggles. Although she has seen counselors on and off over the years, she continues to have nightmares related to her attacks and has difficulty trusting people.
Christine is one of 84 women involved in a long-term study of the impact of childhood sexual abuse, led by University of Southern California psychologist Penelope Trickett. The research began in 1987, when Trickett began interviewing a group of girls in the Washington, D.C., metro area who had recently been reported to child protective services as victims of sexual assault. The children and teens, ages six to 16, came from working- to middle-class families (in general, middle- and upper-class families are less likely to be reported to protective services).
Over the years Trickett has uncovered a disturbing pattern. Although individual cases vary, people who have been victims of assault at least once in their youth are at greater risk than the general population for later assault. In other words, despite having survived traumatic experiences already, these individuals are more prone tofall prey yet again.
To date, numerous papers from other research groups have confirmed this pattern, suggesting that sexual trauma in childhood or adolescence increases the odds of another attack or abusive relationship in adult women by somewhere between two and 13.7. (Whether the pattern holds true for men is unclear because of a dearth of studies.)
The finding is not simply an artifact of an individual's socioeconomic class or environment. Trickett and her collaborators have found that female peers from the same communities who did not suffer this trauma did not have the pattern of repeat victimization. In addition, Trickett and her collaborator Jennie Noll, a psychologist now at Pennsylvania State University, have found that women who have experienced childhood sexual abuse are more likely than such peers to be in violent relationships, to show a higher rate of obesity and to suffer financially.
These findings add urgency to efforts to pinpoint why so many victims of childhood sexual abuse are trapped in a cycle of victimization and to explore why some are able to overcome their trauma. Increasingly, researchers are turning to a psychological phenomenon known as emotional dysregulation, or an inability to manage emotional responses, as a possible explanation for the risk these former victims carry. If these scientists are correct, then identifying victims of childhood sexual abuse early and providing them with targeted treatments might set them on a safer, more promising path into adulthood.
Missing the signs
A variety of complex factors may leave victims of sexual assault at greater risk for repeat attacks. For one, early sexual experiences can lay a blueprint for behaviors and expectations in adult relationships. As a result, chronic or repeated abuse may lead to unhealthy beliefs about how to create a relationship. “One core belief might be that I can't trust the people who are supposed to support me,” says David DiLillo, a University of Nebraska–Lincoln psychologist. “Another schema might be that I have to provide sex on demand, that I'm not an active participant in decision making about the sexual activities that I engage in.” In consequence, former victims may not recognize an aggressor's inappropriate conduct until it is too late.
In addition, much of the literature shows that women who experience early sexual trauma suffer from symptoms of post-traumatic stress disorder (PTSD) and may attempt to “escape” their pain by using sex or substances. These behaviors can, in turn, put people at greater risk.
In certain cases, past trauma can even desensitize individuals to possible danger. In 2013 University of Denver psychologists Ryan B. Matlow and Anne P. DePrince found that outcomes can differ depending on whether someone has been abused repeatedly by the same perpetrator, what they call chronic victimization, or attacked multiple times by different people, known as revictimization. In a sample of 236 women of different backgrounds, the researchers found that each pattern of abuse was associated with different symptoms of PTSD.
Using a series of psychological tests, the researchers discovered that women who had been chronically victimized did their utmost to dodge discussion or thoughts related to the trauma. This pattern of active avoidance might reflect the fact that they depended on the perpetrator in some way, making it necessary to distance themselves from negative events to maintain the relationship.
In contrast, women who were victimized by a variety of assailants often struggled to recall important details of their trauma. These passive avoiders tended to feel emotionally numb and estranged from other people. Their responses might, in a sense, shield them from the intensity of their painful memories, but they also left the women less equipped to detect the warning signs of a future attack.
Physiological changes typical of PTSD may underlie this desensitization. Prolonged exposure to stress and stress-related hormones (primarily cortisol) can lead to dysregulation of the body's stress-response system, called the hypothalamic-pituitary-adrenal axis. Even 10 to 12 years after experiencing childhood trauma, the women in Noll and Trickett's longitudinal study showed signs, in blood tests, of poor regulation of this system, leaving them less equipped to identify and respond to risky situations. Furthermore, research has shown that chronic exposure to high levels of cortisol caused by stress can leave young people vulnerable to other health problems, including obesity and brain changes that affect memory and cognition.
The confluence of factors that contribute to revictimization paints a bleak picture. Yet researchers also see cases where young people appear to break the cycle and find healthy relationships—even after severe childhood abuse. By studying these cases, psychologists can start to spot the distinctions that might make all the difference in determining how to intervene.
One factor that seems to influence the long-term impact of childhood sexual abuse, Noll says, is “how someone understands the trauma, how much she felt fear or blames herself.” For example, one woman in the study had sex with her stepfather to keep her younger sisters from getting beatings. It happened multiple times. But today she is adjusted and lives a normal life. “Why is it that she's okay?” Noll asks. “Maybe she knew it wasn't her fault. Maybe she felt like she was protecting her siblings.”
As one might expect, Noll and Trickett have found that women who escape a dangerous or unstable environment generally fare better in future relationships than those individuals who are trapped throughout childhood. This finding underscores the importance of teaching young people to report inappropriate or violent behavior, enabling an adult to intervene.
Another approach comes from a growing community of psychologists who suspect that learning to recognize and express emotions could help many at-risk individuals escape the pattern of repeat victimization. DiLillo and his colleagues have noted that many victims of sexual trauma in childhood show signs of emotional dysregulation. This condition can manifest in several ways, such as displaying emotions that are too intense or aggressive for a particular situation, difficulty calming down when upset or avoidance when dealing with a negative situation. Previous research has also indicated that some victims show signs of borderline personality disorder, a condition marked by instability in their moods, behavior and relationships—all consequences of emotional dysregulation.
Emotional dysregulation can arise as part of a person's temperament, but it often occurs in childhood, when kids do not learn how to master challenging emotional situations. Kim Gratz, a psychologist at the University of Mississippi Medical Center who collaborates with DiLillo, explains that serious trauma at a young age can produce intense emotions that are incredibly hard to regulate, particularly as children are still developing the skills to manage them. And some family environments pour fuel on the fire, Gratz observes: “Maybe their elders are invalidating their emotions, telling them they shouldn't feel what they feel or punishing them when they express negative emotions.”
DiLillo and Gratz are studying a group of 488 women ages 18 to 25—some of whom experienced sexual trauma and some of whom did not—to test their theory that emotional dysregulation plays a pivotal role in revictimization. The studies are ongoing, but the team has started to publish results that suggest that former victims do, in fact, have more trouble managing their emotions. A 2015 paper based on findings from 106 of these women who experienced PTSD symptoms following sexual victimization found that those with the most intense emotional dysregulation were more likely to make use of cocaine, alcohol, opiates and other substances. The researchers have preliminary data suggesting that these women are also more likely to turn to sex to cope with their negative emotions. Taken together, the findings indicate that helping patients manage emotions more effectively could be a useful strategy in preventing these women from turning to risky sex or substances, which in turn could protect them from the cycle of victimization.
One thing is clear, DiLillo says, just raising awareness of risk is not enough—at least not for those who are most vulnerable. Approaching “college women and talking to them about the risks of sexual assault is less effective than one would hope,” he says. “Knowledge of risk rarely changes behaviors. You have to have a little more of an intensive individualized intervention.”
Perhaps the most promising treatment is dialectical-behavior therapy (DBT), an established approach to addressing emotional dysregulation. Marsha M. Linehan, a University of Washington psychologist, developed DBT in the 1970s to treat patients with borderline personality disorder. The approach builds on the principles of cognitive-behavior therapy, which focuses on teaching patients to restructure unhelpful thoughts and behaviors. DBT develops skills in four areas: stress tolerance, mindfulness, regulation of emotions and interpersonal communication.
Patients are given strategies for asking for what they need in various relationships, knowing when to stand up for themselves and dealing assertively with conflicts. “On the one hand, we can teach these patients how and why they feel the emotions they feel, and on the other, we can train them in how to moderate arousal,” Gratz says. “If emotional dysregulation is the central cause for revictimization, we're hoping that treating it will help them through the course of their lives.”
Few large-scale studies have looked expressly at the effectiveness of DBT for women with a history of chronic sexual victimization. A small study published in 2002 by psychiatrist Marylene Cloitre, now at the National Center for PTSD, is relevant. Cloitre recruited 58 women with PTSD related to childhood abuse and enrolled half in a 12-week program that incorporated many components of DBT; the others were added to a waiting list that offered minimal treatment. Compared with the waiting-list group, women who received therapy showed great improvements in mood-regulation skills—as measured by scores on a series of psychological tests—even months after the treatment was complete.
Since then, several small studies have been conducted to test the effectiveness of DBT in treating PTSD from childhood sexual trauma. But thus far none has definitively shown that such treatments can prevent revictimization in patients with a history of previous sexual assault. Even if the approach is validated, it will be an enormous challenge to provide access to DBT, a costly therapy that is often not covered by health insurance.
Research on sexual revictimization is only in its infancy, but early findings may help counteract some of the harmful stigma and self-loathing associated with this behavior pattern. As researchers develop a fuller picture of sexual trauma's complex effects on body and mind, society can learn to stop blaming these victims and start understanding them.