Trauma, abuse and PTSD

Authored by Henry Strick van Linschoten

In the context of the complete module, this section will discuss the immediate and wider aspects of how trauma, abuse and PTSD can influence sexuality, sexual health and well-being, and give views about the relative importance, strength and weakness of associations often made, all with a view to what is useful for the psychotherapeutic practitioner in their work practice with clients.

Abuse and trauma

Abuse is a term that is used to emphasise the mistreatment, unfairness, improperness, or sometimes wrongness of actions inflicted by one or more people on other humans (or animals). Wikipedia manages to produce a list of 117 types of abuse. Abuse by definition is inflicted by people. Abuse is a subcategory of the traumatic or traumatogenic events which are an essential part of the criteria for PTSD.

Trauma emphasises the harm or injury done to the victim of trauma. Trauma requires sentience by the “receiver” of the trauma. Psychotherapists commonly use trauma for what others would specify as “psychological trauma”, and that usage will be followed here. Even for psychological trauma, there is a tension between focusing on the objective qualities of what has been done, the subjective experience of the “victim” of the trauma, and whether or not the trauma produces lasting consequences, possibly in the form of PTSD, complex PTSD, or other disorders or behaviour patterns that a person exhibits in the longer term and that were not there before the traumatic event or series of events (e.g., years after having suffered trauma a person may be diagnosed with a substance use disorder, or a sexual dysfunction, without formally fulfilling the criteria for PTSD).

There is a huge literature about trauma and abuse (see for instance the Confer online modules about Trauma and dissociation, and about Intergenerational trauma), which will not be referred to here. The most important distinctions are between chronic and event-related abuse; and between trauma with or without an interpersonal dimension (e.g. without: earthquake, fire, drowning, disease, accidents).

What is sexual in sexual violence?

A key distinction in the context of this module is sexual or non-sexual. This already involves complications as regards possible pathways for impact, effect and causality. It is easier to assume that childhood sexual abuse, or sexual aggression or assault, would influence a person’s sexuality, than if the trauma is more related to violence, or caused identifiable lasting physical and / or medical injury, whether to genitals or other parts of the body. However, this is far from being confirmed by research studies.

Some extra confusion may be caused by the often-discussed position that “rape is not about sex, it is about power, violence and control”. On an analysis of the literature, it turns out that this statement is seen much more in popular than in academic or scholarly literature. There seem to be few if any academic feminists and / or lawyers who take the position that it would be incorrect to say that rape is an act of sexual violence. Some of the many nuances of a feminist rethinking of the legal and non-legal concepts of rape can be found in Whisnant (2017), including extensive references.

In controversial areas such as the ones in this section, words and language are often surprisingly fluid. It seems that international nomenclature is moving towards a generic non-legally defined overall term of “sexual violence”, as the one most helpful for delineating a range of actions or events with enough commonality and stability to study and evaluate statistically.

Trauma and abuse, sexual and non-sexual, physical or more emotional and intangible, can all do damage to the person, their confidence, their sense of self, their feeling of security including attachment security, and their sexual health, well-being and self-confidence. For the impact on sexuality, it is enough to fully accept the basis of sexuality discussed here as the mainstream view – that sexuality is an integral part of the combined mind-body health and well-being of people, and that sexuality is closely intertwined with the whole personality and people’s sense of self

However, it is very important when causality goes in one direction, not to believe that you can turn it around, and work backwards. It is possible that a person’s sexuality is influenced by trauma. But how it is influenced – what effect it has – how severe it is, is different from person to person. Generally, PTSD and complex PTSD are not 100% certain (“deterministic”) consequences of being traumatised (further see the discussion on this in Confer’s online module on Trauma and dissociation). Even for the most severe types of traumatic events, PTSD follows never in more than 50% of people – and much less for less severe types of traumatic event. Different people can react very differently to the same trauma or traumatic event; the same is true for the effect of trauma and abuse on sexuality. And given that trauma can affect sexuality, one cannot conclude that every disturbance or problem in people’s sexuality has a background in traumatic events or abuse – far from it. Sexuality is influenced by many factors; almost everything in a person’s life history can influence sexuality, sexual preferences, behaviour and identity.

Psychotherapists need to live with this uncertainty and are trained to do so. They need to be closely listening to and being attuned to the unique individuality of the client in the room. Hear what they say. But avoid jumping to theoretical conclusions that sexuality could be “mapped back” to particular events, including childhood events, trauma and abuse. They might; they might not. As in other areas of psychotherapy, we need to distinguish what we observe from what theories we are familiar with – theories that usually only consist of a statistical or probable or possible association or correlation – not a single-cause causality that would allow one to work backwards.

Causes of sexual dysfunctions

There is a range of significant potential causes other than trauma or abuse that can be found for sexual problems, and that can have major effects:

• violence (which is at least as rife a problem in society and human history as anything involving sexuality)
• poverty
• attachment insecurity
• independent mental health issues
• medical problems
• genetic factors
• epigenetic factors
• prenatal influences in the womb
• learning
• parenting
• family dynamics
• culture
• religious factors
• dogmatic beliefs, including dogmatic beliefs supposedly supported by science
• power and authority
• superstition
• moral panics

The ease with which it has often been tried historically to associate unusual sexual behaviours with trauma or abuse has been paralleled by a neglect or denial of studying the negative impact on sexuality of religious ideas, attitudes, rules and misinformation. The influence of religion has been less often named and formally studied, but its impact is clearly there. And religion has a place in a list of possible causes of unusual behaviour, on a par with the many others listed above.

Some specific sources

The following is a list of sources that illustrate the picture outlined above, and give more detail as well as more specific examples.

Ruth Cohn. Toward a Trauma-Informed Approach to Adult Sexuality: A Largely Barren Field Awaits its Plow (Cohn, 2016)

O’Callaghan et al. Navigating Sex and Sexuality After Sexual Assault: A Qualitative Study of Survivors and Informal Support Providers (O’Callaghan et al., 2018)

Smidt and Platt. Sexuality and trauma: Intersections between sexual orientation, sexual functioning, and sexual health and traumatic events (Smidt and Platt, 2018)

Tepper. Sexuality and Disability: The Missing Discourse of Pleasure (Tepper, 2000)

Rausch et al. Women with exposure to childhood interpersonal violence without psychiatric diagnoses show no signs of impairment in general functioning, quality of life and sexuality (Rausch et al., 2016)

Layton. Trauma, gender identity and sexuality: discourses of fragmentation (Layton, 1995)

Balint. Trauma and object relationship (Balint, 1969)

van der Kolk. The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development (van der Kolk, 1996)

Laplanche and Pontalis. Fantasy and the origins of sexuality. (Laplanche and Pontalis, 1968)

It is worth referring back here to the Introduction, and its definitions developed by the WHO (2006) of sexuality and of sexual health.

Analysis of a detailed example

On the detailed scientific and research side, the following analysis of some specific issues may be of interest.

“Sexual trauma” is a good example of a problematic trend that can be found especially in the sexological field, but also widely in psychotherapy, psychology and psychiatry. Outside the areas of scientific standards, peer-reviewed research in respected academic journals, and reputation based on experience and professional standing, there is a wide (and growing) field of uncertain status – the media; “popular psychology”, aptly named; social media memes; gurus; commercial interests clever at manipulating news and at times research; and plain appeals to power and to authority, as found in religion, spiritual movements, but also in states and parastatal organisations.

In this other field almost anything goes and can be advocated and supported. It is the aim of this module (and of Confer in general), not to jump on bandwagons and follow fashions, but to apply enough critical screening to allow the users of Confer’s CPD to trust that there is a reasonable evidentiary or research backing for what is included.

“Sexual trauma” is a good example to analyse in some detail. Broadly, the popular meme would be that “naturally” sexual problems would be often, or even mostly, “caused” by sexual trauma. The word “caused” is rarely used, as it would only encourage readers or listeners to ask how the causation is established, and to apply critical thinking. But causation is very much implied.

Trauma as a cause is itself a problematic term, as it is too often taken as suggesting that trauma or traumatic would be a quality of certain events – as the Greek original meaning of the word as physical damage or injury suggests. However, psychological trauma really refers to a long-lasting and persisting damage done to the mind, or more likely, the combined mind-body, in the aftermath of and as a result of (caused by) an event, or series of events. As stated in the Study guide of the PTSD module, there are no examples of classes of events that even exceed 50% in their capacity to lead to PTSD. And most events only result in PTSD at considerably lower percentages. In talking about trauma, in order to produce clarity in what one means, it is essential to state if one means a potentially traumatogenic event or series of events, or if one means the PTSD (or possibly other well-defined and ascertainable set of symptoms) caused by the events. In which case it is never an event, but a person with an affliction, set of symptoms, or disorder, that one is talking about. It is possible to ask someone if they have been abused as a child; if they have been sexually assaulted; if they have been involved in a traffic accident or earthquake; if they have been tortured. But one does not ask a person to self-diagnose with PTSD – just as a medical doctor would not do that with a disease. Symptoms yes – like a high temperature; headache; pain in the knee. But not a diagnosis of a disease.

Similarly, even when one rejects DSM / ICD type diagnoses, and wants to move the whole world to switch to using “formulations”, I do not believe that anyone has seriously proposed that it would be possible to let people produce their own formulation. A person is the ultimate authority on what they feel, what they perceive and what they experience – but the whole idea of diagnoses, formulations, or any form of communicatively effective choice of words, is that they are interpersonally derived, and not only based on an agreement between two people, but that there is an element of comparability achieved by believing that if one person calls a particular pattern or set of symptoms X, another person would, based on the same interview or contact with the person concerned be fairly likely to use the same formulation or designation of X for that person (reliability).

Apply this now to sexual trauma. First, there is an apparently closely related term that is “military sexual trauma”. This has been used in a number of studies and articles and is clearly circumscribed. It is a legal term, defined in the United States Code, the compilation of all US federal laws, where it is used numerous times. It is defined as – “psychological trauma, which in the judgment of a VA [Department of Veteran Affairs] mental health professional, resulted from a physical assault of a sexual nature, battery of a sexual nature, or sexual harassment which occurred while the Veteran was serving on active duty, active duty for training, or inactive duty training.”

The disadvantages of using this definition for any psychotherapeutic discussion are clear:

• It is a legal term; not medical, not psychological, not psychiatric, not psychotherapeutic
• In its definition it refers back to other legally defined constructs, such as assault, battery and harassment
• Its occurrence is made dependent on the judgement of a “mental health professional” working for a government department, who makes a judgement about whether the military sexual trauma is caused by the legally defined potentially traumatogenic events or not

There is a disturbing level of trauma caused by sexual assaults on (and sexual harassment of) American military personnel. To establish legal responsibility, to agree on levels of financial support, to agree on the funding for treatment or other rehabilitative activity, to keep statistics, and to work on the process of reducing military sexual trauma, this definition is not only useful, but essential. But nothing of the work done using this definition will generalise to psychotherapeutic work with people who have not been working for or trained by the US military.

Going to the more general term of “sexual trauma”, unfortunately this does not seem to be used to any degree in research work. Other than its use in “military sexual trauma”, it was used occasionally as a synonym for sexual abuse in publications before 1995. One of the very few later examples of its use was in Smith and Freyd (2013), where its usage, other than extensively referring back to sexual abuse, fits a number of times with Freyd’s choice of the keyword trauma in Freyd (1996)’s concept of “betrayal trauma”, which focuses largely on the violation of trust by people or institutions, and deals more with childhood abuse than with a general scope of sexual assault that includes periods in life later than childhood.

Even if there would be an operational definition of “sexual trauma”, or a connection with generally used and precisely defined other concepts, the general research work about trauma functions differently from what is implicitly assumed in the popular idea that there might be a connection between sexual trauma and sexual problems or dysfunctions. Almost all research in the trauma field first connects different classes of traumatogenic events (with the wide scope including childhood physical, sexual and emotional abuse; sexual rape and assault and sexual harassment; physical attacks and interpersonal violence; non-personal life-threatening events such as earthquakes or epidemics; torture, war and terrorism) with certain well-defined disorders such as PTSD, complex PTSD, depression, anxiety, dissociative disorders and others.

There do not appear to be studies directly linking some or all of the usual traumatogenic events with sexual dysfunctions or paraphilic disorders. It has been made abundantly plausible that traumatogenic events are correlated with a range of disorders and symptoms. There remains a hesitation about the significance of this correlation, as in the central case of PTSD the traumatic events which form part of the definition (“actual or threatened death, serious injury, or sexual violence) have not been selected independently of the prior knowledge that these events are likely to stress and disturb people. So there is already a degree of definitional circularity at the heart of the paradigmatic usage of trauma. (To clarify this: “Why does this person have PTSD? Because they were exposed to trauma. What is trauma? Any event that can lead to PTSD symptoms.” is not an example of scientific reasoning. There is clearly more to the concept and theory formation around PTSD than this – but again, in popular summaries of the theory the risk of this circularity is ever-present.) However, it is clear that overall, carefully used, PTSD is a helpful concept.

The origin of sexual dysfunctions in other disorders is hard to demonstrate – in fact should hardly ever occur. Why? Because DSM-5 clearly states in all the criteria for sexual dysfunctions that the diagnosis of the function as a sexual dysfunction is not appropriate, and cannot be given, if the sexual dysfunction is “better explained by a nonsexual mental disorder or as a consequence of severe relationship distress or other significant stressors and is not attributable to the effects of a substance, medication or another medical condition.” To be clear what this means: If a person has erectile disorder (ED) because they have alcohol use disorder (are an alcoholic), they don’t have alcohol use disorder AND ED – with the alcoholism explaining or causing the ED; they only get diagnosed with the alcohol use disorder, which directly explains the difficulties with erectile functioning.

So, while it is true that traumatic or traumatogenic events can be regarded as the cause of PTSD, or other (especially anxiety-related or dissociative) disorders, if they subsequently lead to sexual dysfunction, under the definition system of DSM they should not lead to a diagnosis of sexual dysfunction. The symptoms are explained by the disorder – which in turn was the result of the traumatic events. “Sexual violence” is one of the traumatic events that are conditions for a PTSD diagnosis. But sexual violence refers to an event or events; not to the trauma – which is a name for a set of symptoms of a person.

To summarise; there is no research connecting “sexual trauma” (assuming that it is defined in a way that links with normal nomenclature) directly with symptoms of sexual dysfunction. This is always mediated by a form of disorder that can be directly related to traumatic events. And if there is such a disorder, under the DSM rules that means that the sexual dysfunction cannot be diagnosed or described as an independent disorder, explainable by something else.

The above analysis can be largely repeated for “sexual violence” – which, while not easy to define itself, at least refers to events rather than to psychological (or medical) symptoms. There still is no research that substantially establishes the cause of sexual dysfunction in earlier sexual violence.

Two examples of research studies directly referring to the above problems can be consulted. Laumann, Paik and Rosen (1999)is one of the rare studies in which it was attempted to directly correlate sexual dysfunction with traumatic events. It covered a sizeable group of people (1750 women and 1400 men). But it suffers from such grave methodological problems, including an inappropriate use of Latent Class Analysis, that its results do not stand scrutiny. Even so, the outcome was very limited, and with small effect sizes, taking the results at face value. Another study about military sexual trauma, Luterek, Bittinger and Simpson (2011), with a small group of female military veterans, shows some findings with a certain correlation between military sexual trauma and PTSD as well as DESNOS, but on the way to showing that result, appears to indicate that the gathered data about childhood abuse would show that there is no correlation between childhood sexual abuse and PTSD or DESNOS – which would contradict a range of existing studies of reasonable quality. It also is methodologically weak, involves a small sample, and does not in fact properly distinguish between military sexual trauma and other non-military sexual violence. There do not appear to be studies in this field of a significantly better methodological quality, or studies suggesting there are markedly strong correlations that can be fairly easily obtained.

References

Balint, M. (1969). Trauma and object relationship. The International Journal of Psychoanalysis, 50(4), 429–435. Retrieved from http://www.pep-web.org/document.php?id=ijp.050.0429a

Cohn, R. (2016). Toward a trauma-informed approach to adult sexuality: A largely barren field awaits its plow. Curr. Sex. Health Rep., 8(2), 77–85. doi: 10.1007/s11930-016-0071-4

Freyd, J. J. (1996). Betrayal trauma: The logic of forgetting childhood abuse. Cambridge, MA: Harvard University Press.

Kolk, B. A. van der. (1996). The complexity of adaptation to trauma: Self-regulation, stimulus discrimination, and characterological development. In B. A. van der Kolk, A. C. McFarlane, & L. Weisaeth (Eds.), Traumatic stress: The effects of overwhelming experience on mind, body, and society (pp. 182–213). New York: Guilford Press.

Laplanche, J., & Pontalis, J.-B. (1968). Fantasy and the origins of sexuality. The International Journal of Psychoanalysis, 49(1), 1–18. Retrieved from http://www.pep-web.org/document.php?id=ijp.049.0001a

Laumann, E. O., Paik, A., & Rosen, R. C. (1999). Sexual dysfunction in the United States: Prevalence and predictors. JAMA, 281(6), 537–544. doi: 10.1001/jama.281.6.537

Layton, L. (1995). Trauma, gender identity and sexuality: Discourses of fragmentation. American Imago, 52(1), 107–125. doi: 10.2307/26304374

Luterek, J. A., Bittinger, J. N., & Simpson, T. L. (2011). Posttraumatic sequelae associated with military sexual trauma in female veterans enrolled in VA outpatient mental health clinics. Journal of Trauma & Dissociation, 12(3), 261–274. doi: 10.1080/15299732.2011.551504

O’Callaghan, E., Shepp, V., Ullman, S. E., & Kirkner, A. (2018). Navigating sex and sexuality after sexual assault: A qualitative study of survivors and informal support providers. Journal of Sex Research, 1–13. doi: 10.1080/00224499.2018.1506731

Rausch, S., Herzog, J., Thome, J., Ludäscher, P., Müller-Engelmann, M., Steil, R., … Kleindienst, N. (2016). Women with exposure to childhood interpersonal violence without psychiatric diagnoses show no signs of impairment in general functioning, quality of life and sexuality. Borderline Personality Disorder and Emotion Dysregulation, 3(1), 1–13. doi: 10.1186/s40479-016-0048-y

Smidt, A. M., & Platt, M. G. (2018). Sexuality and trauma: Intersections between sexual orientation, sexual functioning, and sexual health and traumatic events. Journal of Trauma & Dissociation, 19(4), 399–402. doi: 10.1080/15299732.2018.1451724

Smith, C. P., & Freyd, J. J. (2013). Dangerous safe havens: Institutional betrayal exacerbates sexual trauma. Journal of Traumatic Stress, 26(1), 119–124. doi: 10.1002/jts.21778

Tepper, M. S. (2000). Sexuality and disability: The missing discourse of pleasure. Sexuality and Disability, 18(4), 283–290. doi: 10.1023/A:1005698311392

Whisnant, R. (2017, June). Feminist perspectives on rape (from the Stanford Encyclopedia of Philosophy). Retrieved from https://plato.stanford.edu/entries/feminism-rape

WHO World Health Organization. (2006). Defining sexual health: Report of a technical consultation on sexual health 28–31 January 2002, Geneva [Technical report]. Retrieved from World Health Organization website: https://www.who.int/reproductivehealth/publications/sexual_health/defining_sexual_health.pdf