Lifelong Impact of Childhood Sexual Violence – Joanne’s story

Objectives

1. To show how childhood sexual violence is kept secret within affected families
2. To show how the consequences of childhood abuse manifest in physical illness
3. To discuss impact on multiple health domains over a lifetime

Narrative Case

Joanne is a 53-year-old patient I have known for over 10 years in my family practice. She has had multiple health conditions including severe asthma, migraines, and most importantly, chronic pain as well as depression that was diagnosed as chronic myofascial pain over 20 years ago. She has been treated for the pain and depression for over 20 years. She still frequently rates her pain as 10/10 in severity and describes the major impact it has had on her life, work and marriage. She went on to develop OA of the back including some disc pathology and pinched nerves leading to intractable neuropathic pain, and has had multiple surgeries, carpal tunnel syndrome leading to surgery, elbow tendonitis leading to surgery, ulnar entrapment syndrome leading to surgery, dental pathology and bone loss leading to surgery, and more. Repeatedly the surgeries fail to calm the various pains attributed to multiple orthopaedic pathologies.

Joanne has a family history of mental illness. 5 years ago, Joanne’s sister attempted suicide. In reading her note and talking to her afterwards, Joanne learned that the man with whom they were living had assaulted her sister sexually. When Joanne was 8, her parents divorced and she and her sister lived with an aunt and uncle. From age 9 through 16, whenever her aunt left the house, Joanne (as well as her sister) were repeatedly sexually assaulted by her uncle. He would hold her down with one hand over her face and force oral sex on her. She describes feeling suffocated and this being the start of her asthma. She has been angry about this but had never mentioned it to anyone until her sister’s attempted suicide, not even when she and I directly discussed this over the many years I knew her. Hearing her sister’s story, she acknowledged her own. She drew her courage and confronted the uncle and actually taped his response to her question “Why did you do this to me all these years?” and he replied, “You never stopped me”. She, with the help of counselling from multiple sources, and with much trepidation, ultimately decided to press legal charges against her uncle, a process that took five further years, all the way to the Supreme Court of Canada. Her uncle was ultimately found guilty. Her depression was now more clearly related to her trauma as posttraumatic stress disorder (PTSD). The stress of this confrontation process itself has had huge impact on her health over a period of about five years, both before the disclosure and after. She describes feeling guilty for never having told anyone before and possibly having prevented him from doing this to her sister, to her cousins and his grandchildren. Her anger is always under the surface.

Currently Joanne is using appropriate medication, working hard to take care of herself, yet still feels “totally debilitated” and says she would like to “amputate her painful right arm” She uses willpower to control the pain along with her long acting opioids and feels she will never be able to return to work. Aside from chronic pain and depression, she is having financial problems, social isolation, nightmares and significant dental problems, which she attributes to her sexual abuse directly. Her asthma may also link to the abuse as vocal chord dysfunction. She attributes vaginal warts and anal pain since childhood as well. Most recently she has been attending the “Darkness to Light” program from the Voicefound organization to help her and she still has court issues as the “victim impact” is still being quantified. She is not yet out of the woods for having come forward. She is a survivor and she is able to see it as a positive step towards reclaiming her wellness however.

Learning Points

[1] Girls in Canada are sometimes subjected to repeated rape by family members and will not be able to discuss the past traumatic issues even when asked directly about this. These are well-guarded family secrets and there are many reasons why. There are resources that can help healthcare providers facilitate this necessary but difficult step in the healing process.

[2] Even as physicians who are well aware that childhood sexual assault puts women at higher risk for many different illnesses, chronic pain, marital problems and depression, we will be dealing with patients who are simply unable to tell their story. The index of suspicion of childhood trauma must go up when dealing with comorbidities such as chronic pain, depression, unexplained pelvic or anal pain and many other chronic debilitating conditions. These are described in further depth in the background information that follows

(3) Guilt and anger are very powerful pathogens. Community resources can help a woman understand past events and put them into context. Police services can help. Family services, psychologists, social workers, and other counsellors as well, as this problem needs a village to solve it. A family physician that knows a woman over time can build trust slowly. Even an astute asthma specialist can help identify the problem. Eyes and ears must be open for the underlying story. The practitioner’s index of suspicion can be honed. The office can have reading material that demonstrates this is a topic that would be welcome to discuss. The environment has to be right, the timing as well. Not all stories are told all at once

(4) Telling a story is not the end of the problem but more like a beginning of healing. Community resources like Voicefound can help.

(5) The physician’s patient records that contain detailed clear accounts of childhood abuse are extremely valuable for the adult seeking legal help, and should remain available to those who seek them. Joanne’s case might have taken far less than 5 years if that information had been available to her.

Background information (related to child sexual abuse)

1. A Review of Child Sexual Abuse Prevalence Studies suggests the child sexual abuse prevalence rate for girls is 10.7% to 17.4%* and the rate for boys is 3.8% to 4.6% .95% will know their perpetrator.
2. The National Clearinghouse on Family Violence has data on prevalence as well as resources for prevention:
3. National Clearinghouse on Family Violence
4. Family Violence Prevention Unit
5. Public Health Agency of Canada www.phac-aspc.gc.ca/nc-cn
6. Canadian data on child maltreatment including sexual and physical abuse and neglect can be found at http://www.phac-aspc.gc.ca/ncfv-cnivf/pdfs/nfnts-2006-maltr-eng.pdf

References

1. Excellent Resources for survivors and for healthcare providers can be found at Voicefound.   http://www.voicefound.ca/
2. A handbook for health care providers summarizes prevalence, traumogenic illness, and how to approach survivors in practice: http://www.voicefound.ca/wp-content/uploads/2011/03/Handbook-on-Sensitive-Practice.pdf
3. Darkness to Light sexual abuse prevention training is available at workshops through Voicefound:http://www.voicefound.ca/events-category/stewards-of-children-training/
4. http://www.d2l.org/site/c.4dICIJOkGcISE/b.6035035/k.8258/Prevent_Child_Sexual_Abuse.htm#.VEW4ibxdWO8