Peritraumatic Pain in Child Sexual Abuse: Children’s Descriptions of Pain as Conveyed in Their Testimonies Following Child Sexual Abuse

Introduction

Child sexual abuse (CSA) refers to a spectrum of sex-related crimes involving various forms of victimization of a child (under the age of 17 or 18; Finkelhor, 2009). These include attempted or actual intercourse, oral-genital contact, fondling of sex organs, or any sort of exposure to adult sexual activity and pornography, and the use of a child for prostitution or pornography (Putnam, 2003). The estimated prevalence of CSA history is commonly assessed between 12%–40% among women, and 7%–17% among men (Barth et al., 2013; Finkelhor, 2009; Stoltenborgh et al., 2011).

The literature on CSA has dedicated considerable attention to its long-term physical and mental consequences (Hailes et al., 2019; Irish et al., 2010). One of the most prominent health-related derivatives of CSA is chronic pain (Finestone et al., 2000; Mehta et al., 2017; Peles et al., 2016; Spiegel et al., 2016). Specifically, findings reveal that CSA survivors experience high rates of genito-pelvic pain (Santerre-Baillargeon et al., 2017), interstitial cystitis/painful bladder syndrome (Mayson & Teichman, 2009), headaches (Lee Peterlin et al., 2007), irritable bowel syndrome (Beesley et al., 2010; Ross, 2005), and fibromyalgia (Häuser et al., 2011).

These increased rates of chronic pain among CSA survivors have been explained through several pathways. Particularly, some explanations highlight the multifaceted interface between mental and physical morbidity, highlighting the hypothalamic–pituitary–adrenal axis (HPA-axis) as potential impediment for appropriate immune system function, and a precursor for inflammation, which may serve as potential mechanisms underlying the link between CSA and chronic pain (Mayson & Teichman, 2009; Nicolson et al., 2010). Another explanation points to central sensitization, a process whereby the central pain system becomes chronically hypersensitive and signals pain despite the absence of peripheral damage (Latremoliere & Woolf, 2009). Third, some findings emphasize the scarring effect of child abuse, as implicated in post-traumatic stress disorder (PTSD; Asmundson & Katz, 2009; Sharp & Harvey, 2001), depression (Nicol et al., 2016) chronic fear, stress (Khandker et al., 2014), and anxiety (Santerre-Baillargeon et al., 2017), as key factors for explaining chronic post-traumatic pain.

Despite these important contributions, one key manifestation of CSA possibly related to subsequent physical and mental morbidity has been left unexplored. Considering that CSA inherently involves pernicious physical offenses inflicted upon a child, a question arises as to whether and how do children experience pain during and immediately following CSA, i.e., peritraumatic pain. Quite alarmingly, to the best of our knowledge, this question has not yet been investigated empirically.

Although direct investigations of peritraumatic CSA pain are lacking, an initial indication for its manifestations may be indirectly gleaned from a few studies conducted with adult female survivors of sexual assault. In one such study, 64% of participants reported experiencing severe pain in at least one body part at the initial medical evaluation (up to 48 hours following sexual assault), and 52% reported pain one week post assault (McLean et al., 2012). The most frequent pain regions reported were genital, head/neck, back, and abdomen. Fifty three percent of women reported at least four body regions, revealing a widespread pain. The findings show that less than half of the pain areas reported were those involved in direct physical trauma during the assault. Another study found that at both six weeks and three months post sexual assault, women survivors reported widespread pain, with the four highest prevalence areas being the head, neck, back, and abdomen. Again, most participants did not experience pain in these regions during the assault (Ulirsch et al., 2014).

In pediatric medical settings, valid pain assessment tools are available, and although adjustments should be made to cognitive development of the child (Drendel et al., 2011), are recommended for all ages (Baxt et al., 2004; Blount & Loiselle, 2009; Merkel & Malviya, 2000). Nevertheless, findings show that assessment of pain is lacking in 20% to more than 50% of cases, especially with younger children (Drendel et al., 2006). Additionally, various other factors buffer pain assessment and treatment of children, such as disparities between perceived and documented pain management (Probst et al., 2005), and inconsistent correlation between pediatric pain intensity and injury severity (Baxt et al., 2004; van Meijel et al., 2019). Notably, findings show that medical staff tend to evaluate the pain of abused children as less intense compared to other injuries (Drouineau et al., 2017). Taken together, it seems that in both medical and forensic arenas, pain assessments are often inadequate.

Pain reflects an intricate noxious subjective experience, including physical, mental, and interpersonal facets (Edwards et al., 2016). The experience of pain holds a significant protective evolutionary purpose, which is structured to protect the organism from probable danger and harm. As such, pain may serve as a defensive mechanism, which signals to the child that something very wrong is taking place. Consequently, pain sensations during CSA may activate defensive strategies, involving various sorts of peritraumatic responses (Katz et al., 2020). Additionally, peritraumatic pain may promote expressions of suffering by the child (either verbal or nonverbal), thus communicating to the perpetrator that his or her actions are harmful.

However, CSA most often involves a counter-validating interpersonal dynamic, as it occurs within supposedly protective and nourishing relationships (Schuder & Lyons-Ruth, 2004). Especially when perpetrated by a family member, CSA essentially involves disregarding the child’s fundamental and developmental needs, including his or her subjective experiences (van der Kolk, 2017). This disregard is a fundamental characteristic of attachment trauma (D’Andrea et al., 2012), and may therefore intervene in the ways the child and perpetrator attend or react to the child’s pain experiences and expressions during CSA. Additionally, it has been postulated that children undergoing abuse may internalize the abusive characteristics, thus altering or eradicating their own subjective experiences (Howell, 2014). Unveiling the experience of peritraumatic pain in CSA may therefore shed light on the complex victimization dynamics and its implications for the short- and long-term subjective experience, and the particular pain sensations it involves.

A central factor that may affect the experience of pain during CSA is peritraumatic dissociation. Somewhat similar to pain sensations, dissociation reflects a valuable defense mechanisms, aimed at detaching oneself from an experience of horror, pain, and helplessness (Spiegel, 2003). Peritraumatic dissociation refers to alterations in the perception of time, space, and bodily sensations, sometimes including out-of-body experiences, depersonalization and a feeling of unreality (Marmar et al., 2004). Although transient dissociative episodes are a common occurrence during childhood, pathological dissociation is more common in traumatized children (Putnam, 1993). Indeed, during CSA incidences, children often dissociate, striving to make sense of an unbearable situation, in which a supposedly protective figure is hurting them (Classen et al., 1993). It is therefore possible that pain sensations during CSA are obscured by dissociative processes (van der Kolk & Fisler, 1995). Although previous findings have shown that dissociation is associated with reduced sensitivity to pain sensations (Defrin et al., 2015; Ludäscher et al., 2010), such processes have been overlooked with regard to peritraumatic pain in CSA.

Peritraumatic pain experiences in CSA may play a significant role in explaining its long-term trauma-related physical and mental morbidity. First, the experience of intensive repeated pain may activate central sensitization, which has been proposed as a substrate of chronic pain and other psychosomatic morbidities (Woolf, 2011). Peritraumatic pain may also be implicated in post-traumatic pain-related symptoms, such as intrusive pain symptoms and pain flashbacks (Macdonald et al., 2018; Salomons et al., 2004). These pain-related post-traumatic symptoms may act as trauma reminders (Schreiber & Galai-Gat, 1993; van der Kolk, 1998), or enhance stress-induced hyperalgesia (Johnson & Greenwood-Van Meerveld, 2014). As such, pain sensations during and a short time following CSA may generate complex physical and mental corresponding mechanisms underlying post-traumatic psychopathology and physical morbidity. To date, the relationship of pain sensations during and immediately after CSA has not been well documented; without this, further research on the relationship of that pain to long-term morbidity cannot be identified.

The Current Study

The current study lay initial foundations for the study of the perception, experience, and expression of pain during and a short time following CSA. The study was conducted by analyzing the statements of 35 children referred for forensic interview following CSA. This method was selected due to the lack of an empirical or clinical framework referring to the issue. Note, however, that forensic interviews with children constitute a unique platform in which an exploration of children’s experiences and perceptions can be conducted before any formal intervention has taken place and the children are still in the abusive context.

The analyses of the children’s narratives were guided by the following research questions: (a) How do children describe their pain during the reported abusive incidents? (b) How do children and perpetrators react to the pain display following the sexual abuse?

Method

Results

Thorough thematic analysis of the children’s narratives identified the following themes: (a) “It was a killing pain really deep inside”: Children’s experiences of pain during sexual abuse; (b) “I was sitting all alone trying to calm myself”: Pain shortly after the abusive incident; and (c) “He said it is painful but fun”: Pain as part of the complex dynamic with perpetrator.

Discussion

CSA and other forms of child maltreatment leave their traces on the subjective experience of self and body. Particularly, it has been postulated that “the body keeps the score” (van der Kolk, 2015), and that trauma may result in post-traumatic orientation to bodily signals (Tsur, 2020; Tsur et al., 2018). Experiences of pain related to CSA may correspond with the essential experience of uncontrollable, invasive, interpersonal manifestations of abuse (Tsur et al., 2017).

The findings of this study provide an initial glance into the intensity, quality, and phenomenology of peritraumatic pain perception and experiences during and a short time following CSA. The children’s narratives reveal that CSA peritraumatic pain is perceived as highly intensive, but often lacking in specific localization. Additionally, experiences of pain in the immediate aftermath of CSA incidents tend to be widespread, presumably indicating hypersensitization. Finally, pain seems to be inherently embedded within the dynamic with the perpetrator that is either directly or silently negotiated.

The children used adjectives such as “terrible awful” to describe their pain during incidents of CSA. Thus, although previous studies assumed no necessary tissue damage in interpersonal trauma (Meeus & Nijs, 2007), the current findings suggest that some tissue damage may take place in CSA. Alternately, it is possible that peritraumatic pain in CSA does not necessarily reflect tissue damage, but rather psychosocial stress-induced hyperalgesia (Johnson & Greenwood-Van Meerveld, 2014). Either way, the current findings uncover a CSA aspect that has been overlooked, and point to the need of further exploration.

Additionally, the children’s narratives imply that while the severity of pain was particularly high, they had a hard time localizing the particular pain sensations. Some children expressed a sensation of deep internal pain—“ just inside”—attesting perhaps to the difficulty to locate pain due to the involvement of internal reproductive organs, which are difficult to comprehend at this age, particularly when lacking familiarity with the functions and sensory aspects of sexual organs. Finally, these descriptions may indicate visceral pain, which has been shown to be highly linked with stress-induced hypersensitivity (Moloney et al., 2015).

Thirdly, the pain was described by several children as invisible, as being “just there.” As earlier presented, peritraumatic dissociation may intervene with pain perception during CSA. In highly dissociative states, pain sensations may be perceived as sensory fragments, which are difficult to comprehend (van der Kolk & Fisler, 1995). Nevertheless, findings reveal that induced dissociation is linked with small, yet significant increases in sensitivity to pain (Horowitz & Telch, 2007). In parallel, the current findings indicate that children experience intensive pain, which, although highly intense, is also difficult to locate. Further research is needed to uncover the role of peritraumatic dissociation and its link with peritraumatic pain in CSA.

Although the findings show that the children struggled with describing their pain, some children used the words “killing” and “burning” to describe the quality of their pain. According to Wilkie et al.’s (1990) study on pain qualities as expressed by children, the word “killing” refers to an affective quality, while “burning” refers to a sensory quality. Other findings identified “hot” or “burning” pain as potentially related to neuropathic pain (Jensen et al., 2006). Although the current findings provide an initial glance into potential pain characteristics and quality during CSA, more research is needed for a clear understanding of its origins and derivatives.

The findings of this study further demonstrate that pain was not only experienced during CSA incidents, but days or weeks afterwards as well. Notably, the children reported pain in body areas not directly involved in the abusive act, such as in the head or abdomen. These findings are in line with findings revealing widespread pain during the short time following sexual assault, which are commonly expressed in head, neck, back and abdomen (Ulirsch et al., 2014). Presumably, such pain may be initial evidence of hypersensitization. As previously detailed, acute pain provides a significant protective mechanism, aiming to avoid further contact with a potentially destructive factor (Latremoliere & Woolf, 2009). This protective process is often further enhanced by sensitization, which occurs following intense or repeated acute pain (Woolf, 2011). In sensitization, the pain threshold is reduced to a level in which the system is more sensitive and alert to further potential threat and damage caused by the injurious factor (Ji et al., 2003; Woolf & Salter, 2000). Thus, the current findings may imply that CSA may activate hypersensitivity to pain sensations.

In line with the recognition of the protective role of pain sensations, pain may serve as a generator of defensive mechanisms against the source of the pain. In the case of CSA, however, the source of this pain, i.e., the injurious factor is a person, often a caregiver, who may have continual opportunities to victimize the child. As such, responses to CSA are suggested to differ from the conservative “fight-flight-freeze” responses, and are intertwined in a complex dynamic with the perpetrator (Katz et al., 2020). Indeed, the children’s narratives uncover a unique function of pain experiences within that dynamic.

Specifically, although pain may provide the child with an opportunity to communicate suffering to the perpetrator, the findings imply that this is not necessarily the case. The way pain is negotiated between the victim and the perpetrator is complex and influenced by the nature of their relationship. The results from the current study indicated two distinct dynamics: the first dynamic characterized perpetrators who are strangers or outside of the family acquaintance, in which their responses to pain before, during and after the abuse were ignoring, dismissing or punishing the children and escalating the violence that was carried by them. The second dynamic was characterized by CSA that was carried by family members, in which before, during and after the abuse, the perpetrators dedicated efforts to reduce or prevent pain and to enforcing abuse relational dynamic. This dynamic being led by the perpetrators who are family members, was elaborated recently (Katz & Field, 2020) in a study which highlights that perpetrators who are family members make intensive efforts in order to maintain a considerably good relationship with the children, avoiding violence in order to secure their continuous access to the children as well as preventing any disclosure.

Taken together, these narratives not only uncover different dynamics involved in the expression and acknowledgement of pain during CSA but reflect the perpetrators’ blatant disregard of the child’s experience. Tentatively, the present findings suggest that such distortion of subjective experiences by the perpetrator is internalized, with children learning to hide, overcome, and not express their pain. In turn, children may develop an ability to counteract pain sensations, presumably arising from their realization that resisting the abusive act may result in greater physical and/or emotional pain.