Ending the Pernicious Impact of Childhood Sexual Abuse

Research suggests that reframing what CSA "means" can support your health.

Posted Apr 19, 2018

Pulitzer Prize-winning novelist Junot Diaz was raped at eight years old by a grownup he trusted. In an April 16, 2018 New Yorker article titled “The Silence: The Legacy of Childhood Trauma,” Diaz writes about the decades he spent stuffing down the pain of his trauma, the alcohol, drugs, multiple women he had sex with, the women he abandoned because he couldn’t bring himself to be honest about the abuse he experienced as a boy.

It’s painful to read about Diaz’s crippling shame and self-hatred. It’s also frustrating to read because it takes so long, and so many words, to reach the point where he finally begins to confront the truth that was there all along: He was not responsible for what happened to him. It was not his fault. He was a vulnerable child when it happened, not a man capable of fending off his attacker—or of distinguishing fact from fiction.

The fiction is what he chose to believe, the meaning he chose to attach to his trauma, the cause of his post-traumatic stress disorder (PTSD) that undermined and controlled him, destroyed his relationships and nearly killed him. The fiction at the core of Diaz’s unhealed trauma can be found early on in his story. “Real” Dominican men, he writes, “aren’t raped.” He continues, “And if I wasn’t a ‘real’ Dominican man I wasn’t anything. The rape excluded me from manhood, from love, from everything.”

Many years pass before Diaz finally “stumbled upon a great therapist.” Yet he still lives with “the fear that someone might find out I’d been raped as a child.”

The light of truth has not fully dispelled the darkness. The abuser of his boyhood continues to exert power over the man because the secrecy continues to fuel the shame. And shame is insidious.

Just ask Conall O’Cleirigh. A staff clinical psychologist in the psychiatry department at Massachusetts General Hospital and an assistant professor of psychiatry at Harvard, O’Cleirigh specializes in the use of cognitive behavioral therapy (CBT) to treat depression and other mood disorders, PTSD, and anxiety disorders, particularly among sexual minorities. His research on gay men has found that the same mental health issues that can put someone at risk for HIV can also prevent someone living with the virus from adhering to his treatment.

In an interview for my book Stonewall Strong, O’Cleirigh said, “The mental health vulnerabilities that gay and bisexual men have seem to interfere with medical adherence and adherence to care. They are the same issues that enable gay men to keep themselves out of sexually risky situations.”

When you add substance abuse, it’s even trickier. “Having a trauma history,” said O’Cleirigh, “managing depression, seems to be as important and influential in managing sexual risk.”

One particular disparity unique to gay men jumps off the page. It turns out that up to 46 percent of gay/bi men who report condomless anal sex--the sexual act with the highest risk of HIV for receptive partners, male or female--also report childhood sexual abuse (CSA). “That is a huge number,” said O’Cleirigh.

In a national study of 1,552 black gay and bisexual men, O’Cleirigh and his colleagues found the men who experienced CSA—or physical or emotional abuse, or stalking, or being pressured or forced to have sex—when they were younger than 12 years old, had more than three male partners in the past six months. The men who had been forced or pressured to have sex as boys were likely to have receptive anal sex.

In another study of 162 men with CSA histories, participants reporting sexual abuse by family members were 2.6 times more likely to abuse alcohol, twice as likely to have a substance use disorder, and 2.7 times more likely to report a sexually transmitted infection in the past year. Not only that, but men whose abuser penetrated them were more likely to have PTSD, recent HIV sexual risk behavior, and a greater number of casual sexual partners. Physical injury and intense fear increased the odds for PTSD even more.

“Having that history is repeatedly associated in every sample of gay men with increased likelihood of being HIV-positive,” said O’Cleirigh. 

He said that since childhood sexual abuse “is very, very common in gay/bi men” it appears to be one of the most significant vulnerabilities that accounts for the disproportionately high rate of HIV among gay men. 

As for intervening to prevent the trauma of abuse from turning into risky behavior, O’Cleirigh said, “We have the idea that we could help prevent new infections if we could identify gay men with a CSA history before they become infected with HIV, and try to address the vulnerability that has been created in them, and see if we can reduce their specific distress around having that trauma history and provide them with specific strategies for reducing their sexual risk.”

In fact O’Cleirigh and his fellow researchers recruited about 5,000 gay and bisexual men who experienced childhood sexual abuse. Based at Fenway Health in Boston, Project Thrive divided the men into two groups, one that received counseling and the other a 10-session therapy component. “It had a good effect on sexual risk,” said O’Cleirigh, “but a modest effect on reducing HIV seroconversion rates over time.”

There was very little difference between men who had either counseling or the “heavy” therapy. “We concluded that childhood sexual abuse interferes with your ability to use public health messaging and condom usage,” said O’Cleirigh. “We hypothesized that it was due to PTSD.”

The effects of childhood sexual abuse can be as unconscious as they are pernicious. O’Cleirigh said people who experience CSA “tend to carry around issues in their head they aren’t aware of, such as ‘I’m not good-looking enough,’ or ‘This abuse happened because I’m weak, stupid, and no one is ever going to love me,’ because they are abused sexually and those are the things they take away from it.”

Another effect is for people to “absent themselves in sexual situations so they can get their rocks off,” he said. “They put themselves on automatic, and in automatic they are not going to ask questions like ‘Does this guy care for me?’ or ‘Is he HIV-positive?’” 

Psychologists call it “dissociation,” this detachment from reality or even from our own bodies. It’s a well-known, though not always healthy, reaction to trauma.

Poppers, pot, meth, and alcohol are only four agents of dissociation that are part of the sex lives of many gay men. A mere coincidence?

“To give you an idea of the level at which this operates,” said O’Cleirigh, “I’ve worked with a client who described to me during a session a Friday night of going home, showering, grooming, douching, putting poppers, weed, and lube in his pockets, and getting ready to go out for the evening. I said ‘You’re preparing for sex.’ He said ‘No, just getting ready to go out.’ His preparations were not fully accessible to him.”

An effective risk-reduction/health-promotion intervention that addresses the effects of CSA could help make this man more conscious of what he was doing to get ready for a night out—and where it was coming from in his psyche.

When he updated me on Project Thrive in late January 2017, O’Cleirigh reported the therapy aspect was “very popular with the gay/bi men who received it.” They treated more than 250 gay/bi men for PTSD related to childhood sexual abuse, helping to increase the men’s coping skills, ability to be more present in their immediate situation, and specific skills to evaluate and reassess these situations.

“Treatments are geared toward giving the men a more realistic sense of the world,” said O’Cleirigh, which is an important ingredient of resilience. “As we say to our clients, we can’t change the fact that you were abused, but you can change.”

One of the most important ways you can change is by rejecting the secrecy and shame of childhood sexual abuse. Put the blame and shame onto your abuser where it belongs. Trauma is not about something wrong with you but about what happened to you.

Drive out the darkness with the light of truth.

John-Manuel Andriote/photo
Source: John-Manuel Andriote/photo