Light at the end of the tunnel

Of great interest is the growth in visits of this ‘RoyalCommBBC.blog’! As more acceptance, coping & awareness of these HIDDEN patterns becomes available – there is ‘light at the end of the tunnel’. Many Survivours are delayed in speaking about their past, which Counsellors-Psychologists are available to help you out. From the ChildAbuseRoyalCommission & NationalRedressScheme sites, the following details are provided. If you feel like you’d like to talk with someone: BlueKnot (ASCA) have provided us extreme help on 1300 657 380. Finding someone you find comfortable, may take some time, yet these are a great place to start.

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Long-term Effects of Child Sexual Abuse (9)

Prevention 

The ideal response to child sexual abuse would be primary prevention strategies aimed at eliminating, or at least reducing, the sexual abuse of children (Tomison, 1995). This review has, however, focused on issues related to the deleterious outcomes linked to child sexual abuse rather than on the characteristics of abusers and the contexts in which abuse is more likely to occur, which are relevant to primary prevention. From the information presented here, the implications are for secondary and tertiary preventive strategies aimed at ameliorating the damage inflicted by abuse, and reducing the subsequent reverberations of that damage. 

Child sexual abuse may be a necessary, but rarely (if ever) a sufficient, cause of adult problems. Child sexual abuse acts in concert with other developmental experiences to leave the growing child with areas of vulnerability. This is a dynamic process at every level, and one in which there are few irremediable absolutes. Abuse is not destiny. It is damaging, and that damage, if not always reparable, is open to amelioration and limitation.

Those who have been abused who subsequently have positive school experiences where they feel themselves to have succeeded academically, socially or at sport, have significantly lower rates of adult difficulties (Romans et al. 1995). Those whose relationship with their parents subsequent to abuse was positive and supportive fared better, and a good relationship with the father appeared to have a strong protective influence regarding subsequent psychopathology (Romans et al. 1995). Even aspects of the parental figures’ relationship to each other seem to have an influence. Expressions of physical affection between parents was associated with better outcomes, and marked domestic disharmony, particularly if associated with violence, added to the damage (Romans et al. 1995; Spaccarelli and Kim 1995). Finally, those who can establish stable and satisfactory intimate relationships as adults have significantly better outcomes. 

There is no reason why a well-organised and funded school system should not provide all children with a positive experience academically, socially or in sport. There is no need to identify and target abuse victims, but simply to make every effort to ensure adolescents have the opportunity to share in the enhanced social opportunities, the increased mastery, and the pleasure of achievement that school should provide at some level to all. 

The encouragement of sport may seem trivial, but it has a protective influence on psychiatric disorders in all adolescents, not just those with histories of child abuse (Romans et al. 1996; Thorlindsson et al. 1990; Simonsick 1991). Similarly in adult life, success in tertiary education and in the workforce is associated with reduced vulnerability to psychiatric problems for the abused and the non-abused alike, but particularly for the abused (Romans et al. 1996).

The secondary preventive strategies of relevance in reducing the impact of child sexual abuse are equally relevant to reducing a wide range of adolescent and adult problems unrelated to abuse. These include improved parental relationships, reduced domestic violence and disharmony, improved school opportunities, work opportunities, better social networks, and better intimate relationships as adults. The list is so familiar as to be platitudinous, but is nonetheless of central importance. 

The model advanced in this paper is of child sexual abuse contributing to developmental disruptions that lay the basis for interpersonal and social problems in adult life. These, in turn, increase the risks of adult psychiatric problems and disorders. If this is correct, then focusing on improving the social and interpersonal difficulties of those with histories of child sexual abuse may be the most effective manner of reducing subsequent psychiatric disorder. 

This argues for tertiary prevention strategies aimed at improving self-esteem, encouraging more effective action in work and recreational pursuits, attempting to overcome sexual difficulties, and working specifically on improving the victim’s social networks and capacities to trust in, and accept, intimacy. This does not imply that established affective disorders or eating disorders should not be treated in their own right, but suggests that focusing on current vulnerabilities and deficits may be more productive than extended archeologies of past abuse in the search of an elusive retrospective mastery. 

Conclusion 

The hypothesis advanced in this paper is that, in most cases, the fundamental damage inflicted by child sexual abuse is to the child’s developing capacities for trust, intimacy, agency and sexuality, and that many of the mental health problems of adult life associated with histories of child sexual abuse are second-order effects. This hypothesis runs counter to the post-traumatic stress disorder model, and suggests different therapeutic strategies and strategies of secondary prevention. 

In practice, both models may be of value. The post-traumatic stress disorder like mechanisms may predominate in the short term, and in those who have been exposed to the grossest form of child sexual abuse. The developmental and social model may carry the weight of causality in the far commoner, but less utterly overwhelming, forms of child sexual abuse. 

References (see Library)

Long-term Effects of Child Sexual Abuse 
by Paul E. Mullen and Jillian Fleming

wwww.aaets.org/article176.htm

GLOBAL Articles …

After reading through the recent WP Articles of Supply and Demand – What about the Truth?, Abuse – Turning a Blind Eye no MoreOfficial: Priest accused of going AWOL & How to Let Go of the Need to Control Others it is noted that the patterns of Child Sexual Abuse is by no means cases of ‘isolated incidents’, ‘sole Predators’ or ‘one-off errors’. In what some have long suspected as an endemic problem, this will also require a common solution. Beyond the Religious basis of Catholicism (where many of these ordeals were hidden; 7% of all Catholic priests in Australia; age at the time of the abuse was 11.5 for boys and 10.5 for girls) , a multi-facetted approach will be needed. Australia’s 5 yr Royal Commission 2013-2017 uncovered many of these ingrained occasions, yet so much more is needed for effective change. It is known that many families of CSA Victims continue to follow their Church beliefs, ahead of acknowledging the wrongful impacts on their targeted child.
Perhaps the ingrained element of Control over our vulnerable stems from Caesar’s control over Rome, Anakin’s/Darth Vader’s control over Resistance (Star Wars), or simply the control dynamics found in many a child’s playground. The 4th Article gives us an outlook of personal stresses with micromanaging our children & spouse. Control of ourselves is a major stage in Dr Perry’s Article, involving personal strengthening stages. There may always be others trying to control us, yet through effective parenting-family-networks light will always be possible.

Fresh sexual abuse claims at The Armidale School

The prestigious NSW private school, where a boarding house mistress admitted to sleeping with several male students, has been embroiled in new claims of sexual abuse by a staff member.
— Read on www.smh.com.au/national/nsw/fresh-sexual-abuse-claims-at-the-armidale-school-20181228-p50ong.html

Long-term Effects of Child Sexual Abuse (6)

Socioeconomic status 

The possible influence of child sexual abuse on adult social and economic functioning has not received the attention it perhaps deserves. The well documented difficulties that sexually abused children experience in the school situation with academic performance and behaviour (Tong et al. 1987; Cohen and Mannarino 1988; Einbender and Friederch 1989) might be expected to negatively influence later educational attainments, and impair the development of the skills and discipline necessary to sustain effective work roles. 

Bagley and Ramsey (1986) noted that those with histories of child sexual abuse tended to have lower status economic roles. A random community sample found women reporting child sexual abuse were more likely to have work histories that placed them in the lowest socioeconomic status categories. (Mullen et al 1994). They were also more likely to have partners whose occupations fell into the lowest socioeconomic groups. This did not simply reflect women with histories of child sexual abuse coming from lower socioeconomic status homes (which they did) but was also a product of a significant decline in socioeconomic status among those reporting child sexual abuse from their family of origin. 

This relative decline in socioeconomic status was most marked for women reporting the more severely physically intrusive forms of abuse involving penetration. This latter group had an odds ratio of over four for such a decline, even following a logistic regression that took into account the confounding influences of family background, social disadvantage and concurrent physical and emotional abuse. 

Interestingly, this decline in socioeconomic status could not be accounted for by simple educational failure, nor was the decline to be explained by a reduced participation in the workforce, or preference for part-time work. The explanation for abused women being in less well paid and prestigious jobs could be that they underestimated their value and sought occupations below their capacities (a failure of self-esteem), or that they were less adept at translating training and opportunity into effective function in the work sphere (a failure of agency). The increased frequency with which those reporting child sexual abuse entered partnerships with men from lower social classes compounded the tendency to decline in socioeconomic status. 

This greater chance of a drop in socioeconomic status relative to family of origin is a crude measure of social and economic failure, and suggests a wide ranging disruption of function that is particularly marked in those reporting the more severe abuse experiences. 

Sexuality and sexual adjustment 

A history of child sexual abuse has been found to be associated with problems with sexual adjustment in adult life (Herman 1981; Finkelhor 1979). Finkelhor (1984) described what he termed reduced sexual esteem in both men and women who had reported child sexual abuse. In a subsequent study, Finkelhor et al. (1989) found that women who reported child sexual abuse involving intercourse were significantly less likely to find their adult sexual relationships very satisfactory. 

An attempt to replicate these findings found no relationship between histories of child sexual abuse and sexual self-esteem, whether in male or female subjects (Fromuth 1986), although there was a suggestion that sexually abused women experienced a wider range of sexual activity and were more sexually active than the non-abused. Greenwald et al. (1990), in a questionnaire study, also failed to establish any significant increase in sexual dissatisfaction or sexual dysfunction in their women reporting child sexual abuse, although they only used a broad definition of abuse and did not analyse their data regarding those reporting penetrative abuse. They concluded that the ‘majority of existing evidence seems to suggest that adult sexual functioning is not significantly impaired in community samples of former female victims of childhood sexual abuse who are not seeking treatment’. 

In a study of a random community sample of 2,250 New Zealand women with a questionnaire and an interview phase, data was gathered on sexual histories including levels of sexual satisfaction and experienced sexual problems (Mullen et al 1994). The average age at which consensual intercourse first occurred, and the frequency of consensual intercourse with peers prior to reaching the age of 16 years, did not differ between controls and those reporting child sexual abuse. When, however, only those reporting child sexual abuse involving penetration were considered, they were significantly more likely to report consensual intercourse with peers prior to 16 years of age. 

The controls and those reporting child sexual abuse were equally likely to have been sexually active in the six months prior to interview, but child sexual abuse victims expressed significantly greater dissatisfaction with the frequency of intercourse, interestingly being more likely to complain of infrequency or an unwelcome frequency. Those with histories of child sexual abuse were nearly twice as likely to report current sexual problems (28 per cent compared with 47 per cent) and for women whose abuse involved penetration, nearly 70 per cent complained of current sexual problems. 

The general level of satisfaction with their sex lives was markedly reduced in those with histories of child sexual abuse compared to controls, an unadjusted odds ratio of 9.4 for overall dissatisfaction with their sex lives that rose to over 12 for abuse involving intercourse. Employing similar questions to those used by Finkelhor (1984) to quantify sexual self-esteem, it was found that significantly more child sexual abuse victims believed their attitudes and feelings about sex caused problems or disrupted their satisfaction in sexual relationships. 

The unease about their own sexuality was most common in those whose reported abuse had involved penetration. There was also a significant increase in the frequency with which the victims complained of what they perceived as negative and disruptive attitudes in their partners that caused sexual difficulties. Fleming et al. (in press) in a community sample of Australian women found that child sexual abuse involving penetration was a significant predictor of sexual problems in adult life, even after taking the family and social backgrounds of the victims into account. 

In the study by Mullen et al. (1994), there was also evidence for an association between a history of child sexual abuse and an earlier age of entering the first cohabitation and an earlier age at first pregnancy. This precocious involvement in an attempt at a permanent union and starting a family was particularly marked for those who had been victims of abuse involving penetration. This association could reflect a search for love and affection away from the inadequate home environment that so often accompanies the more severe forms of child sexual abuse. Sadly, in those who had been victims of the more intrusive forms of child sexual abuse, their attempts to establish relationships and families were likely to founder. 

There is also evidence that women who report child sexual abuse are at greater risk during adolescence of sexually transmitted diseases, teenage pregnancy, multiple sexual partnerships, and sexual revictimisation (Gorcey et al. 1986; Nagy et al. 1995; Russell 1986; Spring and Friedrich 1992; Fergusson et al. 1997). In an Australian study, Fleming et al. (in press) found that child sexual abuse, in particular abuse involving penetration, was associated with increased risks of being raped as an adult and of being the victim of domestic violence. 

These findings support the hypothesis that the exposure of children to the sexual advances and acts of adults places the victim at risk of later sexual problems. The more extreme and persistent forms of abuse produce greater disruption of the child’s developing sexuality. The age at which the abuse occurs might be expected to influence the extent of the long-term damage, and child sexual abuse occurring during the pre-pubertal stages of development is perhaps particularly likely to be traumatic. Currently, there are no adequate data on this relationship between age at abuse and subsequent sexual problems. 

On the basis of clinical observations, it has been suggested that women exposed to child sexual abuse may in early adult life respond by heightened anxiety about sexual contact (with avoidance of relationships), or a paradoxical promiscuity (in which the victim devalues herself and her sexuality). What constitutes promiscuity tends to be a highly subjective evaluation, and women with a history of child sexual abuse are more ready to respond judgmentally about their prior sexual behaviour by labelling it promiscuous than would non-abused woman with a similar range of sexual experiences. This reflects not changed sexual behaviour, but changed attitudes to one’s own sexuality. 

However, there is evidence that in those whose abuse has been particularly gross (in terms of physical intrusiveness, frequency, duration or closeness of relationship to abuser), there is an increased risk of precocious sexual activity with its attendant risks of teenage pregnancy and social ostracism. It would be surprising if the traumatic introduction to sexual activity constituted by child sexual abuse did not place the child’s sexual development in some degree of jeopardy. Studies such as those of Fromuth (1986) and Greenwald et al. (1990) that did not detect any negative long-term effects of child sexual abuse on adult sexuality probably had samples lacking a sufficient number of those exposed to more seriously intrusive abuse and, by their methods of analysis, the damage inflicted by the more severe forms of abuse was diluted with results from subjects reporting inherently less traumatic abuse experiences.

Women in a random community sample who had reported child sexual abuse were asked what problems they attributed to this abuse. They volunteered sexual problems in nearly 20 per cent of cases, and less than 3 per cent added a belief that they had behaved in an unduly promiscuous manner as adolescents in consequence of the abuse (Mullen et al. 1994). Over 50 per cent of the victims of incestuous abuse in this sample regarded the child sexual abuse as having affected their sexual adjustment as adults. This contrasts with only 5 per cent who attributed mental health problems in adult life to their histories of child sexual abuse. 

Similarly, in an Australian study (full reference needed), 17 per cent of those who reported child sexual abuse, when asked whether the abuse had had any long-term effects, reported they believed it had damaged their sexual lives. These self-evaluations certainly underestimate the actual impact of child sexual abuse on the levels of psychopathology, but emphasise the extent to which child sexual abuse is regarded by victims as disrupting subsequent sexual development. 

The sexual problems reported so frequently in those subjected to child sexual abuse, particularly of the more chronic and physically intrusive types, may be conceptualised in terms of the disruption of the developing child’s construction of sexuality and the nature of sexual activity. Child sexual abuse may well create for some victims a construction of sexual intimacy contaminated by exploitation and coercion. The lack of mutuality and benevolence implicit in a child being used as the object of an adult’s sexual acts is a disastrous introduction to the possibility of loving sexual relationships. That experiences of sexual abuse, particularly when repeated or when involving a breach of what should be a caring and protecting relationship, leave no residual damage seems an inherently unlikely proposition.

Long-term Effects of Child Sexual Abuse 
by Paul E. Mullen and Jillian Fleming

wwww.aaets.org/article176.htm

Familiar? Child sex abuse victim finally speaks out after decades of shame

Thinking back to the times Brett Sengstock was molested as a young boy makes him want to vomit.

Even seeing photos of Frank Houston causes him to breakdown.

After 30 years of silence and shame, Mr Sengstock has finally decided to come forward because he says he is tired of others speaking for him.

Breaking down in Sunday’s night’s 60 Minutes program sharing his horrific story, Mr Sengstock recounted the graphic details about what happened to him starting when he was seven years old.

The predator was Hillsong founder Brian Houston’s father, Frank Houston, a high-profile pastor who used his position of power to sexually abuse young boys.

Decisions around how the matter was handled were made by Brian while he was head of the Pentecostal movement, the Assemblies of God in Australia.

As a young boy, Mr Sengstock said he considered Frank Houston royalty. He was leader of the Assemblies of God in New Zealand and when he visited Mr Sengstock said it was like the Pope coming to town.

He would stay with the Sengstocks when he came to Australia.

“He would come into my room and lay on top off me,” Mr Sengstock said.

“I couldn’t speak. I could not speak. I couldn’t scream, I couldn’t push back, I just went rigid and I couldn’t breathe, I was petrified.

“(He would say) ‘You’re my golden boy, and you’re special to me,’ and all these sort of things, which, as an adult now, I look back at, it makes me want to vomit.

“When you do that to a child you murder them, you take everything away from them, there’s nothing left.”

The abuse continued until Mr Sengstock was 12 but at 16 he finally decided to tell his mother what had happened. He was shattered by her response.

In a statement on its website, the Hillsong Church said Brian Houston “acknowledges the inexcusable crimes committed against” Mr Sengstock.

“It is misleading that the report failed to mention the many who knew about this issue before it came to (Brian Houston’s) attention,” the statement said.

“Pastor Brian was the one who actually took action when he learned of it as evidenced to by the transcripts of the royal commission readily accessible to the public.

“From the day Frank Houston was confronted by Pastor Brian, he never preached again.”

He became emotional when recounting the sexual abuse he received from Frank Houston. Picture: Channel 9

“She turned around and said to me that you don’t want to send people to hell, and stop sending them to the church,” he said.

When his mother finally revealed what happened 20 years later, without telling him, the matter was “quietly” dealt with.

Frank Houston confessed and paid Mr Sengstock $12,000 for his forgiveness.

The matter was never reported to the police, even when Brian Houston found out about his father’s actions in 1999.

Frank Houston died in 2004. Many didn’t know of his actions until Mr Sengstock spoke to the Royal Commission into child sex abuse in 2014.

Brian said he believed it should have been up to Mr Sengstock to report his father to the police when he first found out about his father’s paedophilia.

Frank’s son Brian spoke to the royal commission into child sex abuse. Picture: Channel 9

The church did strip Frank Houston of his credentials and he retired on a pension with no one the wiser.

It was not until a letter to church members in 2001 that they suspected something serious had taken place.

In the letter the church described his acts as a “serious moral failure”. They would later learn they were criminal acts.

In interviews during the commission, Brian said he “didn’t have any doubt that it was criminal conduct”.

“Rightly or wrongly, I genuinely believed that I would be pre-empting the victim if I were to just call the police at that point”.

After the Royal Commission Mr Sengstock sought compensation, but was not successful because he could not prove the Assemblies of God in Australia was responsible for Frank when the abuse happened.

REFERENCED: https://www.news.com.au/lifestyle/real-life/news-life/child-sex-abuse-victim-finally-speaks-out-after-decades-of-shame/news-story/ecaab6cdf6e38deeb3d4fe31025d14f7

Long-term effects of child sexual abuse (4)

Dangers of post-traumatic stress model

The belief that child sexual abuse is not only a potent cause of adult psychopathology but can be understood and treated within a post-traumatic stress disorder framework has spawned a minor industry in sexual abuse counselling. Though many working in this area have shifted, on the basis of their clinical experience, to broader conceptualisations, there remains a considerable vested interest in a specific post-abuse syndrome.

There are also political agendas linked to seeing child sexual abuse as a product of misdirected and ill controlled male sexuality (which it is), and as independent of social circumstances and family background (which it isn’t). Herman’s (1992) description of child sexual abuse as one of the combat neurosis women suffer from as a result of the sex war neatly conflates the post-traumatic stress model with the political agenda of some feminists.

The understandable wish to avoid repeating the deplorable error made in domestic violence of blaming the victim (Snell et al. 1964) can lead to an insistence on looking no further than the perpetrator (and often just his maleness) for an understanding of why abuse occurs. This potentially impoverishes research aimed at identifying the social and family correlates of child sexual abuse that constitute risk factors for such abuse. The knowledge of such risk factors is essential to the development of programs aimed at primary prevention.

Family risk factors

Child sexual abuse is not randomly distributed through the population. It occurs more frequently in children from socially deprived and disorganised family backgrounds (Finkelhor and Baron 1986; Beitchman et al. 1991; Russell 1986; Peters 1988; Mullen et al. 1993). Marital dysfunction, as evidenced by parental separation and domestic violence, is associated with higher risks of child sexual abuse, and involves intrafamilial and extrafamilial perpetrators (Mullen et al 1996; Fergusson et al. 1996; Fleming et al. 1997).

Similarly, there are increased risks of abuse with a stepparent in the family, and when family breakdown results in institutional or foster care. Poor parent­child attachment is associated with increased risk of child sexual abuse, though it is not always easy to separate the impact of abuse on intimate family relationships from the influence of poor attachments on vulnerability to abuse (Fergusson et al. 1996; Fleming et al. 1997).

Disrupted family function could, in theory, be related to child sexual abuse because of the disruptive influence of a perpetrator in the family. However, given the majority of abusers are not immediate family members, it is more likely that the linkage reflects a lack of adequate care, supervision and protection that leaves the child exposed to the approaches of molesters, and vulnerable to offers of apparent interest and affection (Fergusson and Mullen in press).

The Long-Term Effects of Child Sexual Abuse (3)

Post-traumatic stress model

The relationship between child sexual abuse and adult psychopathology tended initially to be conceptualised in terms of a chronic form of post traumatic stress disorder (Lindberg and Distad 1985; Bryer et al. 1987; Craine et al. 1988). This model focused on trauma-induced symptoms, most particularly dissociative disorders such as desensitisation, amnesias, fugues and even multiple personality. The idea was that the stress induced symptoms engendered in the process of the abuse and have reverberated down the years to produce a post-abuse syndrome in adult life.

In its more sophisticated formulation, this model attempts to integrate the damage inflicted at the time to the victims’ psychological integrity, by the child sexual abuse and the need to repress the trauma, with resultant psychological fragmentation. The latter manifests itself in adult life in mental health problems, and in problems of interpersonal and sexual adjustment (Rieker and Carmen 1986). The post-traumatic stress model found its strongest support in the observations of clinicians dealing with individuals with histories of severe and repeated abuse. It was also often linked to notions of a highly specific post-abuse syndrome in which dissociative disorders were prominent.

Traumatogenic model

In the United States, a less medicalised model for the mediation of the long term effects of child sexual abuse was proposed by Finkelhor (1987) with his ‘traumatogenic model’. This suggested that child sexual abuse produced a range of psychological effects at the time and, secondarily, behavioral changes. This model predicts a disparate range of psychological impairments and behavioral disturbances in adult life which contrasts with the post traumatic syndrome model with its specific range of symptoms. Finkelhor’s model, though less medical and symptom-bound, pays only scant attention to the developmental perspective. It cedes primacy to the psychological ramifications of the abuse with little acknowledgment of the social dimensions. Only in recent years have attempts been made to articulate the long-term effects of child sexual abuse within a developmental perspective (Cole and Putnam 1992), and to attend to the interactions between child sexual abuse and the child victims’ overall psychological, social and interpersonal development.

Long term effects of child sexual abuse (2)

Early Research

The manner in which the long-term effects of child sexual abuse have come to be conceptualised reflects, in no small measure, the very particular circumstances that surrounded the revelation of child sexual abuse as an all too common event in the lives of our children. The first phase of modern research into child sexual abuse was not triggered by observations on child victims, but by the self-disclosures of adults who had the courage to publicly give witness to their abuse as children. These early self-revealed victims, exclusively women, had often been the victims of incestuous abuse of the grossest kind, and plausibly attributed many of their current personal difficulties to their sexual abuse as children. This contrasts with the emergence of child abuse as a public health and research issue that has been driven by the observations of professionals caring for abused children.

Implications

The way child sexual abuse was placed on the public and health agendas put a stronger emphasis on the adult consequences of abuse than on the immediate implications for an abused child. It also emphasised the psychiatric implications of abuse because self-declared victims tended to focus on these, and these revelations often occurred in a broadly therapeutic context with mental health professionals. Early research into the effects of child sexual abuse frequently employed groups of adult psychiatric patients (Carmen et al. 1984; Mills et al. 1984; Bryer et al. 1987; Jacobson and Richardson 1987; Craine et al. 1988; Oppenheimer et al. 1985) which further reinforced the emergence of an adult-focused psychiatric discourse about child sexual abuse. It should also be noted that the manner in which child sexual abuse was rediscovered (for it had been well recognised in the 19th century) and the nature of the advocacy movement which placed child sexual abuse firmly on the social agenda also provided an almost exclusive emphasis on female victims and incestuous abuse. The implications remain largely unexplored of the abuse of boys (which for abuse of the most intrusive kinds involving penetration rivals in frequency that of girls), and of the fact that the majority of abuse is not incestuous.

https://royalcommbbc.blog/2018/12/21/long-term-effects-of-child-sexual-abuse/