‘DON’T TELL MUM’: THE WOES OF THE SEXUALLY ABUSED CHILD

Atrocious!!! That may be the only adjective to describe the video. I find 'horrible' less a word. Only a psychopath could watch that shot in a euthymic mood. Certainly, this vicious, grisly episode would not even be acceptable in the wrestling world – not even a match between John Cena and the Undertaker. There was a clear intention to kill – or at least, break the spinal cord of the 18-month-old baby. Yet the clip was as real as it can be. The nanny's gruesome deeds reminded me of my favorite Ga phrase “Gbɔmɔ ehiii”, and the millennia old debate as to whether humans are inherently good or bad. Perhaps you sighed when you learnt the horrific incident happened in Uganda – far away Uganda, you said. I was relieved too, at least! Yet you cannot tell what happens next door or in your absence.

Globally it is estimated that up to 80 to 98 % of children suffer physical punishment in their homes, with a third or more experiencing severe punishment resulting from the use of implements. (International Center for Assault Prevention, 2014; WHO, 2013). Over 53,000 children died worldwide in 2002 as a result of homicide (WHO, 2003). Child abuse occurs even in most advanced nations. In 2010, an estimated 1,560 children (over 4 children each day) died from abuse and neglect in the United States (U.S. Department of Health and Human Services, 2010).

In Ghana, most cases of neglect, emotional, physical or sexual abuse among children go unreported partly because of contextual factors (cultural, religious, ignorance of the law etc). Yet poor statistics do not imply non-existence. It only shows our unpreparedness to recognize and protect our children and grandchildren. This write-up discusses the psychological repercussions and treatment modalities of one of the most prevailing and dreadful form of child abuse in Ghana – child sexual abuse.

On the average, about three (3) cases of child sexual abuse are reported to the Child Protection Unit of the Department of Child Health of the Korle-Bu Teaching Hospital each week. One of these cases often requires surgical interventions. The perpetrators are not aliens – they are step-fathers, uncles, cousins, family friends and school mates. Unquestionably, child and adolescent sexual abuse victims suffer some immediate and long term traumatic psychological problems. These include, but are not limited to difficulties with trust (including patterns in relationships); emotional, behavioral and cognitive reactions to sexual abuse; and the risk for future victimization (Child Welfare Information Gateway, 2014). These issues are interrelated. The management of victims of child sexual abuse is multifaceted, requiring the medical examination, the legal system (prosecution of the perpetrator), psychotherapy, and relocation of the victim to reduce fear of re-experiencing the abuse. Often, relatives could not notice their child was being abused until after several episodes. Can you list the physical and behavioral signs that may suggest a child may was being sexually abused? What education or prevention strategies can parents and teachers offer?

This write up highlights the nature of these psychopathologies and outline areas of psychological interventions for the first two – difficulties with trust/relationship problems, and the emotional reactions to sexual abuse. The remaining issues will be addressed in subsequent write-ups.

Trust
Victims of sexual abuse develop object relations problems (difficulty in relating and trusting significant others) – particularly the ability to trust other people. In the case of intra-familial sexual abuse, the caretaker, who should have been a protector and a limit-setter, rather exploits the child and violates the boundaries of acceptable behavior. Trust issues become worsened when the victim also experiences other maltreatment or traumatic experiences in the family. Children and adolescents who are sexually abused consider the offenders as persons in a position of authority over them and thus feel compelled to comply. Victims thereafter have difficulty trusting persons in positions of authority in the future.

Interventional Strategies
The clinical psychologist first explores the feelings of the victim and helps the child understands that this was a bad adult who betrayed the victim's trust – not that it was the child's fault. The clinician then creates circumstances in which the child gradually develops positive experiences with trustworthy adults in order to ameliorate the damage to the child's ability to trust. This may involve rehabilitating the child and/or creating opportunities for appropriate relationships with adults, mentors, or other relatives.

Emotional Reactions to Sexual Abuse
Children and adolescents who experience sexual abuse usually react emotionally by feeling responsible for the abuse and having an altered sense of self.

Feeling responsible. Victims may feel responsible and guilty for the sexual abuse for not having stopped it. Similarly, positive aspects of the abuse, such as physical pleasure, the special attention given by the offender, or an opportunity to have control over other family members because of sexual relationship may later make the victim develop self-blame.

Interventional Strategies
The Clinical Psychologist helps the child understand intellectually and accept emotionally that the child was not responsible. The adult sexually abused the child; the child did not sexually abuse the adult. It was the adult's job – not the child's – to stop or prevent the abuse.

Altered sense of self. Guilt feelings and the invasive and intrusive nature of the sexual activity impact negatively on the child's sense of self and self-esteem. The victims may develop altered sense of their bodies, as they see themselves as markedly different from their peers. The victim may feel that the loss of their virginity meant a change in their bodies.

Interventional Strategies
The task of the therapist is to make victims feel whole and good about themselves again. Interventions are geared to help the victims view themselves as more than merely victims of sexual abuse. Normalizing, assertiveness training, confidence-enhancing and ego-enhancing activities, such as doing well in school, participating in sports, getting involved in club activities can be very important in the victim's recovery.

Anxiety and fear. The victim may develop phobic reactions to the event, the offender, and to other aspects of the abuse. Experiences that evoke recollections of the abuse come to elicit anxiety. In some children this anxiety and phobias become pervasive and crippling because of the level of avoidance they engage in to reduce their stress.

Interventional Strategies
The Clinical Psychologist engages the victim in a series of interventions that allow her/him to gradually deal with the abuse and related phobias and anxiety in ways that usually avoid excessive stress and allow mastery. Interventions such as discussions, play therapy, ventilations and systematic desensitization are employed.

Children and adolescents who suffer child sexual abuse in particular may require both medical and psychological interventions. The aftermath consequences of unreported, unexplored and unresolved child sexual abuse cases are weighty and inescapable. Early child education about sexuality and preventive techniques are helpful. Promptly report all cases of child abuse to the appropriate authorities. The Child Protection Unit at the Department of Child Health, KBTH exists to provide both medical and psychological interventions. Reach the Unit through a designated hotline: +233573134032.

Writer: Richard Appiah
(Clinical Psychologist)
[email protected]