- Patients abused as children often experience a diverse range of ongoing health problems, including mental and physical health problems, which increases their healthcare utilisation rate compared with those who have not been abused136
- Many patients have never told anyone about their abuse, or if they have, have not been believed. Many also have not made a link between their current health issues and their childhood abuse212
- Health practitioners need to recognise that child abuse is associated with a higher incidence of comorbidity: mental health issues, suicidality, drug and alcohol problems and chronic disease in adults136 Level 1 A
- A trauma-informed approach to care across all human and health sectors services, as well as trauma specific services, may assist patients who have experienced abuse as children3 Practice point
Child abuse has been outlined in detail in Chapter 6, including definitions, health consequences, and identification and management including mandatory reporting. Although the majority of child abuse is by someone known to the child, a number of state investigations into institutional child abuse and the National Royal Commission into Institutional Responses to Child Sexual Abuse have established that these issues have stayed hidden for long periods of time. It is apparent that many survivors have been unable to disclose, and if they have were often not believed either as a child or an adult. It is also clear that child abuse often occurs in multiple forms concurrently and frequently has long-term effects on survivors.
This chapter explores the possible presentations of adults in general practice who were abused as children, including physical, emotional and sexual abuse, neglect and growing up in situations of domestic violence. Research suggests that adults abused as children are at increased risk of further victimisation as adults.213
Experiences of sexual abuse as a child can affect later adult offending or victimisation. One study that examined the relationship between child sexual abuse and subsequent criminal offending and victimisation found that both male and female child sexual abuse victims were significantly more likely than non-abused people to be charged for all types of offences, in particular violence and sexual offences.213
There has been no national, methodologically rigorous study of the prevalence or incidence of child abuse and neglect in Australia as there is currently no consistency in data collection. There are, however, a number of recent studies that consider one or two abuse types in detail, or have superficially measured all individual abuse types.
Prevalence estimates for physical child abuse range from 5% to 18%, with the majority of studies finding rates between 5% and 10%. Studies that comprehensively measured the prevalence of child sexual abuse found that:214–224
- women had rates of 4.0–12.0% for penetrative abuse and 13.9–36.0% for non-penetrative abuse
- men had rates of 1.4–8.0% for penetrative abuse and 5.7–16.0% for non-penetrative abuse.
Rates of neglect of both genders, along with physical and emotional abuse in general practice populations, are less researched.
The Australian Institute of Health and Welfare indicates that, in 2011–12, there were 252,962 notifications involving 173,502 children in Australia, a rate of 34.0 per 1,000 children. Of the notifications, there where 48,420 substantiated notifications of child abuse in Australia.120 As there is a level of under-reporting that occurs in relation to abuse, these statistics reveal that a substantial percentage of children and young people are abused. Consequently, a significant number of Australian adults who were abused as children may still be experiencing the after-effects of their abuse.
Children are most likely to be abused within the family or by people known to them. The ASCA support line has documented 4376 cases over 3.5 years, with 1686 of these recording the relationship of the perpetrator to the survivor. It was found that 64% of callers were abused by their immediate family, 19% by extended family, 10% by a family friend, 21% by perpetrators in institutions (for example religious, educational, in care and health institutions), 2% by strangers and some by multiple perpetrators.225
The way in which an adult may perceive their childhood abuse experiences will vary greatly depending on a range of factors. The needs of each patient will therefore also differ. Anecdotally, it has been suggested that some adult survivors appear to have experienced little or, at times no effect, although many will experience a profound effect on many aspects of their lives, without the right treatment, throughout their lifespan. Many elements influence how well a survivor copes, including the type/s of abuse experienced, frequency, duration, family life, response to disclosure, and adult experiences of abuse and violence.
The role of GPs
Child abuse in all its forms often has long-term sequelae and health implications. It is important to consider the possibility of prior trauma or abuse in a diversity of presentations in general practice. Most patients will be unlikely to disclose their traumatic experience to GPs unless they know how to ask. To optimise patient care, GPs need to keep the possibility of trauma in mind in all presentations, to case-find or ask if there are clinical indicators and respond appropriately when patients do disclose a history of abuse.212
In an effort to establish the prevalence of adverse health outcomes in relation to childhood abuse, a 2012 systematic review identified 124 studies that investigated the relationship between child physical abuse, emotional abuse, or neglect and various health outcomes. The meta-analysis provides suggestive evidence that child physical abuse, emotional abuse, and neglect are causally linked to mental and physical health outcomes.136
For example, emotionally abused individuals are three times more likely to develop a depressive disorder than non-abused individuals. Physically abused and neglected individuals also had a higher risk of developing a depressive disorder than non-abused individuals. Other mental health disorders associated with child physical abuse, emotional abuse or neglect included anxiety disorders, drug abuse and suicidal behaviour. This group of adult survivors also had a higher risk of sexually transmitted diseases and/or risky sexual behaviour.136
Some survivors who have been abused as a child may adopt strategies to enable them to cope. Some of these – for example, smoking, alcohol and drug abuse, physical inactivity and overeating become risk factors for adult health issues. Other strategies can include psychological mechanisms such as dissociation (a defence mechansim which allows the survivor to compartmentalise their lives), or behavioural disturbances such as self-harm. In the long-term, these strategies are often not constructive and contribute to long-term morbidity and mortality. When GPs are not educated about these strategies, they often perceive the patients as being manipulative or attention seeking. A trauma-informed lens enables GPs to understand patients’ presentations in the context of their lived experience and respond appropriately.
Child abuse has also been correlated with a diverse range of ongoing health problems.136,226 Patients who are survivors of child abuse may present to general practice in some of the following ways, illnesses which have been found to have a much higher incidence:136,226,227
- anxiety, panic attacks
- chronic depression
- chronic gastrointestinal distress
- eating disorders
- personality disorders
- multiple somatic symptoms
- drug and alcohol abuse/smoking
- chronic pain
- sexually transmitted diseases
Major illnesses, including cancer, chronic lung disease, fibromyalgia, irritable bowel syndrome, ischaemic heart disease and liver disease have also been linked to childhood abuse. The increased incidence of smoking is a confounding factor for these diseases.136 Women with a history of child sexual abuse are also more likely to utilise medical care at a greater frequency than women who have not been abused.226 They may have complicated presentations and not respond easily to treatment.
Research shows that survivors of child abuse may experience flashbacks of prior traumatic events at any time during their adult life. Trigger factors may include:
- the birth of a child
- themselves or their child reaching a certain age
- the death of the perpetrator (eg family member)
- watching a television program relating to incest
- a particular place or smell.
Flashbacks may present associated with:
- sleep disturbances
- perceptual disturbances, and
- anxiety at times of sexual activity.
Experiences of physical, sexual, emotional abuse or neglect can result in low self-esteem and difficulties with trust, and impinge on the ability to form close relationships. Survivors may fear for their safety and have difficulties caring for themselves. Asking about family relationships when they were children and the abuse of alcohol by their parents may provide clues.
Disclosure only occurs in a relationship of trust.228 However, trust may take some time to develop as adult survivors of child abuse have been previously abused rather than cared for in prior relationships of ‘trust’. Patients who have been abused tend to have a very negative sense of self. This makes it more difficult for them to care for themselves, seek help and to follow advice. GPs may be able to help by providing a safe space in which they can discuss their needs and which over time, can help establish trusting relationships. It is of course crucial to always treat these patients with dignity and respect, provide them with a sense of hope and optimism and help them improve their capacity for self-care by helping them to achieve a healthy and safe lifestyle. Sometimes this will additionally entail referral to a health professional with specialist skills in supporting adult survivors.
To assist with this education, the RACGP has produced a DVD, The hidden factor: the effects of child abuse on adults. A resource for GPs and other health professionals. In this DVD, three women tell their stories of abuse in order for doctors and other health professionals to have a better understanding of the factors that helped with the healing process. The DVD is available from the RACGP.
ASCA has produced Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery,230 which will assist you to understand the presentations of patients who have experienced child abuse and respond appropriately. The Practice Guidelines contain two sets of guidelines, which have been officially recognised as an accepted clinical resource by the RACGP.
The first presents the principles of trauma-informed care, which work from a premise of ‘do no harm’, focusing on what happened to the person rather than what is wrong with the person. Implementing trauma-informed care involves working in the domains of:
- Safety – ensuring physical and emotional safety
- Trustworthiness – maximising trustworthiness through task clarity, consistency and interpersonal boundaries
- Choice – maximising consumer choice and control
- Collaboration – maximising collaboration and sharing of power
- Empowerment – prioritising empowerment and skill-building.
The second presents the principles of clinical treatment of ASCA, stressing the importance of establishing safety as a core part of any therapeutic work.
There are also the Australian Guidelines for the Treatment of Acute Stress Disorder and Post Traumatic Stress Disorder (refer to Further information).
Helpful ways of working with survivors of sexual abuse
In the report, It’s still not my shame: Adult survivors of child sexual abuse, semi-structured interviews were conducted with five target groups including survivors (28 individuals), service providers (67 individuals) and service managers (17 individuals).229 These were conducted in metropolitan and country areas in South Australia. A significant number of survivors spoke about the usefulness and importance of survivor groups in addressing some of the effects of the abuse. They suggested that these groups helped to reduce the sense of isolation, promote a shared understanding and challenge self-blame.
Other helpful practices included:
- being believed
- not being judged
- working from a narrative approach
- availability of services outside of office hours (eg groups in the evenings)
- assurance of confidentiality
- complementary therapies – for example, music and art therapies.
Unhelpful ways of working with survivors
It was not uncommon for survivors to have negative experiences in accessing assistance. Commonly reported issues were:
- not being believed or listened to
- lack of trained counsellors
- time constraints
- the worker presenting as the only expert
- being only medicated for the presenting issue – for example, depression
- being blamed for the abuse
- gender/age barriers imposed by agencies for accessing a service
- sexuality barriers, particularly for gay and lesbian survivors
- lack of continuity of workers.
GP ongoing care
For patients who have been disempowered in childhood as a result of their abuse, the trauma-informed principle of being able to choose from a range of treatment options is an important part of their care. Appropriate treatment options to consider with the patient may include individual counselling/therapy, referral to specialist service, therapeutic groups and self-help groups.
It is important to note that certain procedures and investigations – for example, Pap smears in some women who have been sexually abused – may be especially challenging for these patients. Providing a choice about having or not having these procedures is empowering for people who have previously been disempowered. It may be appropriate to use the concept of ‘continual consent’ if you think a patient may feel uncomfortable with a particular procedure or investigation. Using this technique, the doctor talks through a procedure, letting the patient know what they are about to do. Throughout the dialogue, the doctor asks the patient if they are comfortable and happy to proceed. This provides the patient with the freedom to stop the procedure at any time.
Survivors may present with physical symptoms that need to be explored, but some of these may be triggered by or stem from the actual abuse. Examples include a sore throat, gagging related to former oral sex, or pelvic pain. Such symptoms of possible prior abuse need to be kept in mind, as does the need to minimise any potential for re-traumatising patients with particular sensitivities.
Patients abused as children have often had their boundaries violated. All workers and practitioners engaging with survivors, including GPs, need to model clear boundaries. They need to do what they can to make their patients feel and be safe and this means being very respectful of the patient’s physical and emotional space. Should they inadvertently intrude on their patient’s boundaries, they may replicate aspects of prior abuse and this can be re-traumatising for survivors. Maintaining the role as a GP while the patient seeks help from the counsellor, psychologist or psychiatrist further models good boundaries and helps provide the comprehensive model of care many survivors need.
GPs can make an important contribution, but may not always be able to provide everything the patient needs. Sometimes they will see patients who are in counselling or who are in need of therapeutic support but are unable or unprepared to access it. Either way, patients with a history of child abuse are likely to be facing a number of challenges and will often require support. A listening empathic ear, respect, and validation coupled with a sense of hope and optimism for future recovery are invaluable.
Keep in mind that resources will vary from one area to another and it is often difficult to find sufficient, adequate or appropriate resources. Information from the ASCA website or ASCA professional support line on 1300 675 380 may be of assistance.
Referrals could be to:
- another GP with training and experience in supporting adult survivors
- a psychologist or psychotherapist with experience and training in working with adult survivors
- an appropriately trained and experienced social worker or counsellor
- a sexual assault service, if it is resourced to see patients who have experienced childhood sexual assault
- a psychiatrist with experience and expertise in working with adult survivors.
The ASCA professional support line has a referral database of practitioners and agencies with expertise and experience for working with adult survivors of child abuse.
It is important to check with the patient whether the gender of the therapist is of concern to them and if so, which gender they would prefer to see. It is ideal to provide a choice of referrals and give the patient the option of returning should the referral not be suitable. It is also important to offer to continue to see the patient in the role of GP while the patient is in counselling/therapy.
The following are two case studies that illustrate these principles
Case study: John
John, aged 35, presents to his GP with his wife, Judy and 5-month-old son, James. Judy says that she has been asking John to see a doctor for some time as she is worried about his anxiety. He has seen a locum doctor who prescribed benzodiazepine. John found the medication helped with symptoms but made him feel sluggish. He has also found over the past few weeks that he needs to take more to get the same effect and he feels more unwell when he doesn’t take it. Judy says, ‘I don’t like him taking the medication, it seems to make him more withdrawn and unhappy.’
John is reluctant to talk, but with encouragement from Judy says that he is really stressed at work. His job as a computer analyst has always been busy, but lately he is feeling very overwhelmed and is worried he is not performing well.
He is irritable and finds himself ‘flying off the handle’ more easily. His colleagues at work have asked him a few times if he is okay. He has had some disagreements with his boss. He says that, while he has generally interacted well with his boss, he is aware that the boss isn’t a very good manager and that this has recently been bothering him. He is finding it difficult to get to work in the mornings and dreads getting out of bed.
Judy says she has noticed that he is not sleeping well and he agrees, saying that he is having difficulties getting off to sleep and wakes early, feeling tired. He has bad dreams that often wake him and he then finds it hard to get back to sleep. These symptoms started about 4–5 months ago.
John’s father had a problem with alcohol and was violent towards John’s mother. He left the family home when John was 9 years old. John has had little contact with him since. John appears to become increasingly distressed through the consult and says: ‘There was some stuff that happened to me when I was young. I thought I’d dealt with it but it seems to be haunting me now. My mum did her best but she couldn’t keep me safe and my dad didn’t care enough.’ John says he worries about his son and fears for his safety. He says, ‘James just seems so small and I’m worried I won’t be able to protect him from the world.’
Over a number of consultations John discloses that he was sexually assaulted as a child over a number of months by a neighbour. This abuse only stopped when John and his mother moved house. Despite his early childhood trauma, John appeared to manage life well, completing his tertiary education, working full time and creating a close nurturing relationship with his wife and close friends. The life stage of becoming a father appears to have triggered symptoms consistent with PTSD related to his past trauma. The prescription of benzodiazepine, while providing some short-term relief, has led to dependence and tolerance and it does not treat the underlying issue and cause of the distress.
This case illustrates a scenario in which the effects of past abuse appear to have been triggered by having a child. This has presented as nightmares and anxiety. John seems also to be having some problems with authority figures – his boss at work, for example – and this would be consistent, as abuse occurs in situations of inherent power imbalance. The benzodiazepine, while providing short-term symptom relief for his anxiety, has not addressed the true cause for the symptoms, which, at the time was not identified. John is ultimately helped over a period of time through sessions with a psychologist. As he works through his abuse issues he comes to understand what was contributing to his anxiety and how it was linked to the birth of his son. He is able to stop using the benzodiazepines.
Case study: Susan
Susan, 21 years of age and living in a country town, presents to your practice requesting a Pap test. While taking a history, Susan reveals that she is dissatisfied with her sexual relationship; she doesn’t enjoy sex, feels uncomfortable and finds it very hard to relax. She asks you if this is normal. Her reason for wanting a Pap test is that she has been talking with her friends about women’s issues and they seemed to think that regular tests were a good idea. Although she is not sexually active at the moment she says she would feel happier to have a full check-up.
On examination, Susan is extremely tense and performing the Pap test is difficult. You stop the examination, coming to the conclusion that to proceed would be detrimental to Susan. Susan is upset and once she is dressed you reflect back to her that the examination was anxiety provoking. She calms down and says that she will come back in a couple of weeks now she knows what is involved. Before she leaves you inquire about any past unpleasant sexual experiences. She repeats that she doesn’t enjoy sex but that she can’t remember anything of a frightening or threatening nature.
One week later Susan reappears at your surgery saying she has been disturbed since the attempted Pap test. She is having strange dreams and has a feeling that something happened when she was younger. She grew up on a small property out of town. After some discussion she says she thinks something happened with her older brother and some of his friends but that the memories are unclear. She is obviously distressed.
Most likely diagnosis:
- sexual dysfunction
- child sexual abuse.
Together you explore the options – for example, counselling/therapy (individual or group) and whether she wants to see a counsellor at the sexual assault centre or an allied health practitioner with expertise and experience in supporting patients with past abuse. Should she not be able to see a counsellor/therapist immediately, it would be important to see her regularly in the interim. You could discuss strategies that might provide some relief to her sleep disturbance; explore her diet, exercise and self-care and assess her supports by way of friends and relatives, encouraging her to reach out to those she trusts and with whom she feels safe. If you were concerned that she was deeply depressed and/or suicidal, you could consider contacting the local crisis team or psychiatric help.
Susan opts to go and see a counsellor at the local sexual assault service. As the waiting period is 3 months you offer to see Susan on a weekly basis for support. She agrees to this arrangement and you are able to work with her to help her feel safe and improve her capacity for self-care. Nine months later she comes to see you for a Pap test. Although Susan is slightly tense, she can relax sufficiently for the examination to be performed successfully. Susan is relieved and says that in counselling she has been feeling that she is making good progress and being able to have a Pap smear is indicative of her progress as well. She thanks you for your involvement.
This chapter has outlined the long-term impacts of childhood abuse as they present in general practice, and issues in management. Louis Cozolino has said, ‘It stands to reason that the most devastating types of trauma are those that occur at the hands of caretakers’.230 GPs need to be aware that early trauma in childhood may underlie a diverse number of physical and mental health presentations. A trauma-informed approach to patients by GPs can help minimise the risk of re-traumatisation and enable pathways to recovery through appropriate referrals to health practitioners with specialist skills in supporting adult survivors.
Please refer to Appendix 7 for resources nationally and in your area.
ASCA Practice Guidelines for Treatment of Complex Trauma and Trauma Informed Care and Service Delivery. Dr Cathy Kezelman and Dr Pam Stravopoulos.
Australian Guidelines for the Treatment of Acute Stress Disorder and Post Traumatic Stress Disorder.
After Abuse – this book, written by Victorian psychiatrist Dr Gita Mammen, outlines types of treatment and may be helpful to GPs trying to find an appropriate referral or seeing patients in a counselling role
Better Access Initiative – the MBS item relating to the GP Mental Health Care Plans may be useful for patients wanting to initiate ongoing mental healthcare.
The hidden factor DVD is available to RACGP members for loan, from the RACGP library: email firstname.lastname@example.org, phone 03 8699 0519
Living well – a website for men who were sexually abused as children or who have been sexually assaulted as adults.