Real World Clinical Blog: On Childhood Sexual Abuse
by Dr. Danna Bodenheimer, LCSW, author of Real World Clinical Social Work: Find Your Voice and Find Your Way
Although all abuse leaves the child psyche in tatters, there is perhaps no other form of abuse as devastating to the developing mind and body as sexual abuse. There are several complex reasons for this fact that are worth revisiting. But most potently, the misunderstanding of what actually constitutes sexual abuse might be part of what makes it so disruptive. We often think of sexual abuse as being linked to intent, when in fact there is rarely conscious intent at work when someone is being sexually abused. Instead, sexual abuse is typically the byproduct of unconscious impulses in the abuser that leave the recipient feeling overstimulated and dysregulated.
Let’s start with the traditional definition of sexual abuse. Colloquially speaking, sexual abuse is considered to be molestation or undesired sexual behavior forced upon one person by another. Unfortunately, this definition leaves out a vast number of experiences of sexual exploitation and abuse. The definition relies on touch as a marker of abuse. It also relies upon the idea that the abuse is undesired, which is just too much of an oversimplification of the reality of how sexual abuse feels.
In 1932, Sandor Ferenczi, a psychoanalyst, gave a speech to a group of fellow clinicians. In this speech, he argued that there was a psychological phenomenon at play, on a societal level. He called this phenomenon “The Confusion of Tongues.” In his presentation, he argued that children are not most frequently sexually abused by penetration or molestation, but instead by overstimulation. He argued that children were sexually seduced by adults who did not know how to better regulate their own sexual impulses and desires. For children, whose sexualities ought to be developing in the closed system of their own psyches, having intrusive involvement by caregivers becomes psychologically difficult to metabolize.
This seduction is not overt and can barely be named by the abuser or the child being abused. For example, a child might be overstimulated by seeing parents watch pornography. Or, children might not know how to manage seeing their parents having sex. Perhaps a child has trouble making sense of overhearing two teachers talking explicitly about the sex that they had last night. Or, perhaps a child has watched a caregiver masturbate in front of the child. None of these examples include a child being touched. None of these examples include a child’s clear capacity to know that they don’t want these things to happen. And none of these examples include a clear level of intent.
Ferenczi was shunned by the psychoanalytic community following his argument for parents’ capacity to seduce their children. While I don’t know the exact nuances of his ostracization, I do think that it is important to begin to think more about the nuances of sexual abuse or sexual impropriety. This is important because many children are struggling with sequelae of sexual abuse but feel as if there is no clear antecedent to this symptomology. They become confused about their own burgeoning sexuality, often feeling tremendous shame, hypersexuality, or a terror about sex in general. They also feel that there is something deeply wrong with them, confused about why they feel as curious and overstimulated around sexual issues as they do.
Recognizing the broader spectrum under which sexual abuse can occur helps us to more properly help our clients. Furthermore, it can take the pressure off both the clinician and the client to find single incidents of sexual abuse. Instead, the focus can shift to developmentally misattuned environments that leave children reeling, in search of how to make sense of the material in their own minds.
Upon recognizing this broader spectrum, it is essential to recognize the idiosyncratic nature of how sexual abuse preys upon the mind. First, sexual abuse tends to rob children of their relationship with truth. Feeling unclear about what they are perceiving and feeling in their own environments, children’s minds start to re-narrate what they are witnessing in favor of a more tolerable script. This flipped script leaves children unclear about whether or not they can safely trust their perceptions. Second, sexual abuse also leaves children with a sense that they themselves are perpetrators. Because the body is inherently aroused by sexual seduction, material, or behavior, children feel that their own bodies wished for this and, therefore, it is somehow their fault. Further, because bodily sensations are experienced as a source of shame, because of their involuntary responsiveness to sexual stimuli, the child tries to disconnect from all the information that the body provides. This can lead to problems with bladder infections, incontinence, or just plain confusion about what the body actually desires.
Our work with sexually abused children almost always leaves us struggling in our own haze of confusion and doubt. The tendency for children to pathologically doubt themselves seeps into our treatment, often leaving us doubtful about how we are proceeding, if we are having any impact at all, or if our children are even telling the truth. Perhaps this is why treatment of sexually abused children has become almost compulsively manualized - aiming us to avoid the inevitable confusion brought on by this work.
To successfully treat children who have been sexually abused, several paradigm shifts are required. This means, primarily, that we need to reconceptualize the possible scope of sexual abuse. This reconceptualization can free us from seeking someone to blame, offering, instead, a refocusing on the suffering client in front of us. Also, instead of fighting the powerful discomfort that comes with working with sexually abused children, we can occupy and tolerate the doubt. The doubt gives us access to our clients’ own psychological experiences, as well as offering them a respite from the demanding doubts in their own minds. We need to, also, recognize the dual impact that sexual abuse has on the mind and the body. While sexual abuse often serves to sever the mind/body connection by creating bodily experiences that are intolerable for the mind to process, our work can re-link these two ultimately inseparable entities by inviting both into the room.
Dr. Danna R. Bodenheimer, LCSW, is in private practice at Walnut Psychotherapy Center in Philadelphia, PA, and teaches at Bryn Mawr College Graduate School of Social Work and Social Research. She provides more of her clinical perspective and tips for developing clinicians in her book, Real World Clinical Social Work: Find Your Voice and Find Your Way.