Time’s Up: Culture of Denial Impacts Mental Health of Sexual Abuse Survivors

A group of Australian researchers recently released an article investigating the interpersonal disclosure experiences of sexual abuse survivors. While sexual abuse is connected to future psychiatric problems, the authors sought to develop a deeper understanding of the issue to inform prevention and intervention efforts. They found that over 96% of their sample met criteria for major depressive disorder (MDD), over 82% met criteria for post-traumatic stress disorder (PTSD), and more than half had considered suicide at some point in their lives. The qualitative timeline analysis suggests that experiences of self-blame, betrayal, and vulnerability arose when disclosure of survivors’ sexual assault experience was ignored, not believed, or met with threats of retribution.

“Overall, our study illustrates the potentially important role that negative disclosure experiences play in generating persisting psychosocial vulnerability in the survivor,” write the authors.

“Women encountering negative disclosure experiences reported an array of adverse psychosocial outcomes in their subsequent lives including social isolation, drug-taking, recurrent or persisting mental disorder and future risk of abuse, including bullying at school. A general state of psychosocial vulnerability that persists over time may be an important foundation for understanding the risk for adult revictimization in child survivors of sexual abuse.”

The authors point to the #MeToo campaign as an unprecedented opportunity to break the silence for all women who have been sexually abused. They aimed to analyze interpersonal responses from family members to understand critical milestones related to the disclosure of abuse, plotting key traumatic events, reactions, and mental health via a qualitative timeline.

Given that almost a quarter of adult women report childhood exposure to sexual abuse and that it is common to experience the first onset of a mental disorder shortly after, the authors suggest that early therapeutic intervention may be critical in halting this trajectory.

Theoretically, disclosure may offer a chance for emotional recovery, though, in reality, it often elicits negative, unsupportive reactions. Feelings of guilt or shame may delay disclosure, though the authors aimed to quantify further and describe the impact of disclosure.

Some studies have attempted to bridge this gap, though they have either failed to include mental health outcomes or have focused on disbelief rather than trying to understand the attribution of victim-directed blame. Further, it is known that betrayal trauma can occur when trust has been breached, and that victimized women may be at risk for later victimization. The authors sought to better understand the timeline and causal relationships between these different experiences.

The researchers elicited a spontaneous account of familial response to the disclosure of sexual abuse, the survivor’s emotional response, and the subsequent psychosocial consequences via a gender-informed narrative history approach. The study was introduced to women by sexual assault counselors at a sexual assault service they were attending.

Women who were not in an immediate emotional crisis and whose last experience of sexual assault was at least a month ago were recruited and subsequently interviewed. The counselor and participant worked together to create a timeline where significant events occurred, focusing on contextual factors, mediating emotional responses, and a description of events that aided or harmed recovery. This allowed researchers to draw temporal connections between the abuse, response of the world to this disclosure, and the survivor’s psychological state.

In nearly half their sample of thirty women, sexual abuse first happened in childhood. Twenty-eight of the women experienced PTSD, and twenty-four women experienced MDD. Negative disclosure experiences during childhood were more strongly associated with meeting criteria for a mental disorder than those that occurred in adulthood. Sixteen of the participants reported experiencing suicidal ideation in their life.

“In cases of childhood abuse occurring outside the home by someone previously known, there was almost universal evidence of general neglect in the care and protection of the child in the family,” write the authors.

“Ten participants (71%) with early childhood sexual abuse reported revictimization as adults. As indicated by the details provided hereunder, being ignored, overtly blamed or threatened for the abuse following disclosure appeared from analysis of the timeline interview data to be most closely associated with the onset of subsequent mental disorder symptoms and future risk for sexual abuse.”

A variety of themes emerged from the data analysis, including being ignored or not believed, being blamed, or being threatened. The authors suggest that self-blame and guilt were associated with being ignored or blamed and that the resulting sense of betrayal may have been psychologically harmful.

“Overall, our study illustrates the potentially important role that negative disclosure experiences play in generating persisting psychosocial vulnerability in the survivor,” write the authors.

“Women encountering negative disclosure experiences reported an array of adverse psychosocial outcomes in their subsequent lives, including social isolation, drug-taking, recurrent or persisting mental disorder and future risk of abuse, including bullying at school. A general state of psychosocial vulnerability that persists over time may be an important foundation for understanding the risk for adult revictimization in child survivors of sexual abuse. The period immediately following a disclosure, therefore, may prove to be a critical window where survivors are particularly susceptible to effects of either helpful or harmful interventions by confidantes.”

With this in mind, the authors proposed several points of improvement and intervention. First, they stressed that parents need to understand that their affirmation and care following abuse is essential. They then called for more ubiquitous legal and welfare interventions, early detection for at-risk children, for trauma-informed care in healthcare practitioners and community agencies, and, ultimately, for societal change to overcome denial and silence.

The #MeToo movement has the power to promote societal change at the community level by highlighting men’s culpability instead of women’s responsibility, and by avoiding denial and victim-blaming.

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Rees S, Simpson L, McCormack CA, et al. Believe #metoo: sexual violence and interpersonal disclosure experiences among women attending a sexual assault service in Australia: a mixed-methods study. BMJ Open 2019;9:e026773. DOI:10.1136/ bmjopen-2018-026773 (Link)