The Meaning of Sexual Abuse

Childhood sexual abuse is a subtype of physical abuse defined as sexual contact between an adult and a child under the age of 18 years of age in which the child is used for sexual gratification. A parental figure who allows sexual contact with a child is also a sexual offender [1]. Sexual violence toward adults includes sexual molestation, rape by strangers, date rape, rape in marriage and rape during war.


Introduction
Sexual abuse is a pervasive problem in psychiatry. Clinicians are in a position to understand sexual abuse on the level of the individual, the family and society and to provide leadership and support for organized social action to address it.
Childhood sexual abuse is a subtype of physical abuse defined as sexual contact between an adult and a child under the age of 18 years of age in which the child is used for sexual gratification. A parental figure who allows sexual contact with a child is also a sexual offender [1]. Sexual violence toward adults includes sexual molestation, rape by strangers, date rape, rape in marriage and rape during war.
One out of three to one out of five females are sexually abused in population studies [2,3]. One out of seven [2] to one out of seventeen [3] males are sexually abused in childhood. Groups that are targeted for sexual violence are those perceived as weak, unprotected and marginalised including children, women and homosexual men and in war those on the losing side [2].
The prevalence of childhood sexual abuse in psychiatric inpatient units is between 43% [3] to 54% [2]. The corresponding prevalence in males is 26% [2] to 25% [3]. It is estimated that the prevalence of rape in adults is 25% in females, 11.8 % in homosexual men and 4.9% in heterosexual males [4]. Research has shown that 64% of sexual offenders of female children are male parental figures and 18% are male relatives. 9% are family friends. 80 % of sexual abuse occurs within the family [5]. Babysitters and others more frequently sexually abuse male children (38%), while fathers and stepfathers are the perpetrators 30% of the time, mothers 18%, sisters 8% and stepmothers 6% of the time. [6].

Aetiology
Sexual abuse is an act of aggression and if it is not actually followed by beating and murder, it nevertheless implies the threat of death [7]. The abuser exploits the victim for sexual gratification but the sexual violence is primarily an act of dominance, terror, revenge and humiliation. Sexual violence is not fixed in our biological nature, but is the result of social processes that create us. It is a cultural product [8].

Individual psychodynamics
Sexual violence is organised around hatred expressed in a sadistic desire to make the victim suffer. Identification with betraying objects initiates the path to revengeful destruction [9]. Abusers frequently have 1) asymmetrical parenting and a fragile male identity [10], 2) significant deficits in empathy as a result of parental deficits [10] and 3) an incestuous nature that varies from tyrannical, domineering, and violent to restrained, shy, ineffectual, dependent and alcoholic [11]. In the socialization process males are taught that sexual partners should be younger and smaller, that heterosexual success is important for gender identity and that males must be dominant in sex. Most perpetrators have a history of childhood sexual abuse and abusive behaviours where abuse is a re-enactment of past experiences. Mothers tend to abuse children who have a special meaning according to problems surrounding conception or birth. The mother denigrates the child as a part of difficulties with separation and her need to regain power and control over the child [12]. Sexual violence toward homosexual men is part of a violent homophobic reaction and can be seen as an attempt to exorcise parts of the perpetrator's self [13]. Perpetrators have low self-esteem, sexual inferiority and feel socially inadequate. The need to dominate and degrade other people is a mask for their weakness and dependency [14]. Perpetrators suffer from pedophilia, antisocial, narcissistic and borderline personality disorder, dissociative disorders, psychosis, and alcoholism.

Aetiology in the family
Family dynamics contribute to the development of individuals who become sexual aggressors. There is a failure of parental empathy and a lack of intra-familial bonding that Kohut sees as the nuclear essence of human beings [15]. A patriarchal family structure enshrines male dominance and reproduces gender dichotomies. Patriarchal families are organised around male dominance and the threat or use of force to induce submission [16]. Men are socialised to use sex as a way of expressing emotions, obtaining power and attaining a sense of adequacy [17]. There is a lack of love in the family such that hate does not exist as an opposite of love, but a substitute for it, and being hated appears more desirable than being abandoned [18]. Chronic destructive emotional dynamics in a family contribute to aggression becoming a goal in itself and this transforms relationships into hostility and destructiveness [19].

The incestuous family
Incest is more common in poor, rural and isolated regions. Most incestuous relationships last from six months to seven to eight years but for coital incest the duration is longer [11]. In these families the marital relationship is broken and the father turns to the children for sexual satisfaction. These families may take a less restrictive view of incest. The mother usually knows about the incest but hides this awareness and is relieved to be free of sexual obligations toward the husband. The father is frequently away for long periods or the mother works and leaves the children vulnerable to the father. The father is either authoritarian or passive and alcoholic. There are family secrets and denial about family problems. Children are neglected and sexual interest is perceived by the children as some kind of affection and love. Either the family is rigid, overly moralistic and intolerant of sexuality or the opposite. Family members are sexualised. There is a lack of respect for appropriate sexual boundaries and personal autonomy [11,20].

Sociocultural aeti
There are endless examples of the endorsement by society of hatred directed toward children, females and marginalised populations [21]. Social sexual violence is organised around the use of authority, power and control of the victim. In political battles sexual violence is used to humiliate and emasculate the enemy. Males promote a sense of entitlement and privilege to rule over females and establish social networks that reinforce female subordination [22].
Societies express hypocrisy toward sexuality and aggression by giving split messages. The explicit message is that there is gender equality, protection and respect for children, tolerance for differences and promotion of freedom and human rights. The implicit message is that of male dominance and power that children and females are possessions of adult males, that there is no tolerance of differences and that freedom and rights are for the powerful.

Psychopathology in survivors
Adults who survive sexual violence suffer greater levels of all types of psychopathology including depression, anxiety, eating disorders, posttraumatic stress disorder, dissociative disorders, borderline personality disorder, psychosis NOS, suicidality and substance use disorders. The earlier and more severe the violence is, the more severe and chronic the disorders are [23]. There are negative long-lasting effects in 78% of survivors [24]. Recent research has focused on the high prevalence of health problems of survivors of sexual abuse including headache, gastrointestinal, gynecological, and panic-related symptoms [25]. Women have been shown to have poorer health, poorer mental health, lower life satisfaction, activity limitations, increased rates of smoking and binge drinking and males have increased rates of smoking, poorer life satisfaction and activity limitations [26]. Females and males with childhood sexual abuse have greater medical illness burden, worse physical function and greater body pain [27]. Childhood abuse in women leads to problems with chronic pain [28] and in particular migraines in association with depression [29] and gastrointestinal symptoms [30].
Depression is the most commonly reported symptom of survivors of sexual abuse and it presents as classical mood disorders or as part of other disorders [23]. The rate of depression is higher when the perpetrator is a family member [23]. Suicide attempts are common [31] and increase with coital abuse [23] and younger age of victimisation [23,31].  Table 1 shows how the meaning of sexual abuse is organised around loss and guilt on the level of the individual, family and society. The operating principles of loss and guilt are the core of depression for the individual. The survivor of sexual abuse has damaged selfesteem and self-respect, loss of trust and respect for others and loss of the belief in justice and fairness. The survivor feels guilty for needing love, protection, respect and acknowledgement. Families who allow  incest or sexual abuse through neglect or innocence face severe loss and guilt that leads to family disintegration. The family fails to fulfill its function of protecting and valuing children. Sexual abuse ruptures attachment bonds and results in the loss of family pride and a belief in family values. Societal and cultural practices are responsible for perpetuating sexual abuse and society suffers loss and guilt as part of a disintegration of the fabric of social morality. When society is unable to prevent sexual abuse, society fails in its responsibility to protect vulnerable people, it damages the individuals who will create the future society, it fails in its responsibility to provide security and survival for individuals, it causes a degeneration of social mores and these actions inhibit the opportunity for spiritual transformation of the civilization. When society fails to prevent sexual abuse, there is a social layer of guilt for affirming aggression, devaluing children, supporting the misuse of patriarchal power and overall these actions inhibit the growth of civilization.

The individual meaning of sexual abuse in the integration process of healing
All the psychopathology that results from sexual abuse is usually identified and addressed by clinicians. But in the treatment, including psychotherapy, whether it is dynamically oriented or cognitive behavioral or dialectical behavioral, the survivor of sexual abuse has to be introduced to the concept of finding a meaning in his/her suffering. It is in finding meaning that the survivor gains the strength to overcome the pain of loss and guilt.

Meaning [32]
Part of the horror of trauma is that it may seem senseless. Innocent suffering such as sexual abuse is the hardest to understand. It shatters the assumption that virtue should lead to flourishing. Striving to be good enough is conducive to happiness but is not a guarantee. It is nearly impossible to accept meaninglessness and senselessness and to stay with these feelings. Survivors are prone to ascribing guilt and the survivor blames him or herself in an attempt to find meaning. Individuals may decide God is punishing them. Self-blame does not resolve the conflict. It is necessary to go deeper. Hope lies in the refusal to accept a world that does not make sense.
As well as problems with logically making sense of trauma, the survivor has to cope with profound emotional problems of guilt, shame, resentment, hatred, vengeance as well as forgiveness and reconciliation. These are existential problems that require personal resolution but this work may be sustained and supported by hope. Hope lies in the refusal to accept a world that does not make sense.

Hope [32]
Survivors of sexual abuse can establish some grounds for hope by trying to make sense of sexual abuse, by taking care of themselves and by cultivating close relationships. Hope requires a synthesis of the emotional motivation to carry on with life and find healing and a reasoned plan of action. Survivors of sexual abuse need someone to support them in developing positive emotions, better self-esteem, a sense of control, better problem solving ability and success in attaining goals.
To hope is to adopt an existential attitude. Hope is an active process of making meaning. In the face of adversity, hope is a virtue that requires courage to sustain.

Foundations of hope [32]
Healing from trauma evolves from attached relationships in which the individual experiences the other person as caring and aware of his/her emotional state. These relationships allow one to make sense of traumatic experience and in the process to develop and maintain a sense of self and loving kindness toward oneself and others. Meaning and self-worth arise from benevolent attachments and hope is founded on all three.

Benevolence [32]
Gaining a sense of basic trust is the first phase of adjusting to life. Hope is based on the belief that there is a benevolent disposition toward each human being that exists somewhere in the universe conveyed through an attached relationship. Hope rests on the ability to rely on others which is a capacity that can be understood as a virtue. Human survival and flourishing are due to others. Sometimes a person must borrow hope from others to survive. Some people find hope in God or in nature but the prototype is a caring attached relationship.
When people are recovering from trauma they may forget that altruism evolved alongside competitiveness and aggression. Loving relationships are the wellspring of hope. Even the most devastating traumas do not obliterate benevolence.

Self-worth [32]
A benevolent disposition towards oneself may include self-love and compassion that arises from within the self. This can be construed as a self-bonding that gives a person strength, vitality and hope. A benevolent disposition towards oneself is a profoundly important factor in sustaining hope and if a survivor can achieve this disposition, he/she is more likely to flourish.

Flourishing [32]
Survivors are more likely to attain happiness if they engage in meaningful projects and develop meaningful connections. This is described as flourishing. It comes from vital engagement and active exploration of the world. These activities reach beyond specific goals to help a person express their individuality. This includes one's actions, thoughts and feelings but also one's attitude toward suffering. There are three domains of flourishing: intimacy, generativity and spirituality.
Intimacy is the ability to confide in others, to express emotion along with a sense of being understood, valued, appreciated and validated. This is what has been described as 'mentalizing' in secure attachments, the feeling of being connected with another person's state of emotional awareness. Generativity refers to investing in future generation by teaching, counselling, leadership or creating something that will endure into the future. Spirituality involves a sense of relatedness with something beyond the self, something divine, vast, grand or transcendent. It is often associated with a sense of awe or reverence. Spirituality concerns the other as well as the self and embraces not only the grand but also the terrifying and terrible.
Trauma, depression and physical illness can all threaten the sense of hope and meaningful engagement with life. Paradoxically, trauma can be a source of flourishing by enhancing an appreciation of the gift of life.
In the final analysis the sort of person a survivor becomes is the result of an inner decision [33]. Striving to find meaning in life is a primary motivational force. This meaning is unique and specific and can only be fulfilled by the individual survivor. Nothing in the world is so effective in achieving survival as knowing there is a meaning in one's life. Human beings should understand they will be questioned by life and that their answer is the way they choose to live their own lives and in this way, they give meaning to the world. There are three ways of discovering meaning in life: 1) through creativity and work, 2) through experiencing or encountering someone or something and 3) through the attitude one takes towards suffering. When one is unable to change a situation, one is advised to change oneself. Suffering is an unavoidable part of life and in accepting the challenge of life people should strive to suffer bravely and give meaning to their lives up until the last moment. Human beings are ultimately self-determining within the limits of endowment and the environment [33] The family meaning of sexual abuse in the process of healing Many trauma survivors report that not being supported by the people they counted on and being blamed for being sexually abused brought more horrendous experiences for them than the trauma itself [34]. Family members first of all need to acknowledge that sexual abuse has happened and to accept that it is wrong and destructive. The family needs to ask for help from the extended family, friends, clergy, therapists and the police. Family members need to support the survivor of sexual abuse and support the proper administration of justice against the perpetrator. Only when family members are willing to take this action does the family have the opportunity to heal. Otherwise, the family remains broken and disintegrated. Someone in the family has to provide the leadership and give family members hope that in accepting reality and in seeking justice, the family will be able to restore proper values and maintain safety and love. Family members need to be able to rely on each other and open the door of trust so that in times of need they can ask for and receive the help they require. If the perpetrator is a family member, the family needs to give a message to the perpetrator that he/she is still a member of the family but that their sexual violent behavior is unacceptable and it must stop immediately. The family must encourage the perpetrator to seek help, to apologize and ask for forgiveness and to search for redemption.

The social meaning of sexual abuse in the process of healing
The personal meaning of sexual abuse is influenced by the social environment. The most beautiful and the most ugly human inclinations are not fixed or biologically given but are the result of social processes [7].
Rape and sexual abuse are not the result of lust or passion but they are acts of power, domination and violence. The first social analysis of rape and sexual abuse was in 1976 [20]. Unfortunately, since that time rape and sexual abuse have continued unabated in all societies in the world. We know that war and situations where there is a lack of social organisation or an obvious social power imbalance lead to a high prevalence of rape/ sexual abuse and murder, sometimes in combination.
There are at least three levels of understanding the social meaning of sexual abuse. 1) First it is a result of child-rearing practices that perpetuate alienation from the self, detachment from feelings and repression of hatred and aggression that is not experienced. This makes people vulnerable to scapegoating others and acting out their aggression on convenient vulnerable objects. 2) Social and economic oppression increase the level of aggression and intrapersonal and interpersonal violence in all societies. 3) Acceptable social behavior is constantly being shaped and reinforced by institutions, media, community and cultural leaders. Helping the individual and the family is not enough. Sexual abuse is the result of a process that is socially caused and organized social action is necessary and essential to restore the humanity of the survivors of child abuse, to re-integrate the family and to restore the integrity of the society.
Herman explains that in order to accept the reality of social trauma that there must be a social context that affirms and protects the victims and joins the victims and witnesses in a common alliance. For society, the social context is created by political movements that give a voice to the disempowered. The systematic study of psychological trauma has therefore been dependent of the support of political movements. The voices of traumatized people can only be heard in society if there is advocacy within the society to support public consciousness [35].

The meaning of psychiatric problems in survivors of sexual abuse
Many psychiatric symptoms that can be seen in survivors derive their meaning through the process of dealing with the trauma of sexual violence. Depression can be seen as a withdrawal and a way of searching for protection and survival. Anxiety is a form of rebellion against an unstable and unsafe environment. Eating disorders are a way of regaining power through control over the body. PTSD is a way of remembering trauma in order to defend against it. Dissociative disorders are a way of escaping through disappearance. Borderline Personality Disorder is a search for a balance between love and hate. Psychosis NOS is a retreat into a different reality. Substance use is an escape from reality into an altered state of consciousness. Suicidal behaviour is a form of punishment and succumbing to victimisation. Physical pain is an expression of how the body keeps the score of emotional suffering.

Conclusions
In order for the individual, the family and society to address the problem of sexual abuse all three need to break through their denial to find a constructive meaning. Survivors of sexual abuse need social support and validation of the injustice of their suffering and the opportunity to integrate their true self in order to find the strength to stop the pattern of destruction. On the level of the family sexual abuse creates the possibility of awakening to strengthen the values of protection and unconditional love without mixing them with sexuality. Children and all family members must be valued as unique individuals. Parents need to accept responsibility for meeting their own needs and solving their own problems without damaging their children. Society needs to recognise and take responsibility for the fact that it allows and perpetuates sexual abuse as evidenced by allowing pornography, pornographic websites and chat rooms that have been setup to lure unsuspecting children into meetings with sexual predators, and selling children into the sex industry.
We consider sexual violence to be a cultural failure. Civilisation began with the restraint of sexual and aggressive drives through taboos against incest and killing. Society has still not developed beyond these restraints. Individuals and families are capable of evolving beyond the destructive expression of aggression and sexuality to develop a cultivated mature society inspired by spiritual values.
The voice of anyone who has been victimized or traumatized in society will not be heard unless there is organized social action to support it. Mental health professionals need to accept responsibility for leadership of organized social action that addresses the legal, correctional, cultural and social management of sexual abuse. As psychiatrists it is our responsibility to promote social action that restores human dignity.