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

Abstract

The literature on child sexual abuse (CSA) has contributed significantly to the understanding of its characteristics, epidemiology, and consequences. Considerably less attention has been dedicated, however, to the subjective experiences of the abused children, and more specifically to their experiences of pain. The current study explored the way children perceive and describe pain during and shortly following incidents of sexual abuse. The sample was comprised of 35 transcripts of forensic interviews following alleged CSA. Thematic analysis of the children’s narratives identified three themes: (a) pain during the abusive incidents, described using words indicating its intensity and quality; (b) pain shortly after the abusive incidents, including weeks later, and (c) pain as embedded within the complex dynamic with perpetrator. The children struggled to localize the pain, mainly using words such as “inside” and “deep.” Moreover, they testified that in the course of the abusive incidents, they were often silenced when trying to communicate their pain to the perpetrators. The children’s narratives provided us with a unique opportunity to learn about the pain not only during the abusive incidents but also following it. Additionally, children described suffering from pain in areas that were not directly injured during the CSA incidents, mainly referring to the head, abdomen and legs. The discussion addresses the potential intervening factors in peritraumatic CSA pain, as well as its potential links with chronic post-traumatic physical and mental morbidity. This study illuminates the necessity to address the complicated links between short- and long-term physical, emotional, cognitive, and interpersonal manifestations of CSA.

Keywords

child sexual abuse (CSA)pain peritraumatic pain pediatric pain acute pain

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

Sample

The sample consisted of 35 Israeli children (22 girls; aged 5–14) who had reportedly been sexually abused. Fifteen children were abused by a relative, such as sibling (4), father (3), uncle (3), mother or grandmother’s spouse (2), grandfather (1), or distant relative (1). Twenty of them were abused by a person outside the family, such as a friend or minor acquaintance (17), complete stranger (2), or a non-relative acquaintance (1). In terms of continuity of the abuse, 24 children experienced multiple and continuous abuse while 11 experienced one-time abuse.

Procedure

The 35 interviews were selected out of all forensic interviews conducted with CSA victims in Israel in 2015 (from a total of 340 interviews, which were randomly selected from the 7,000 interviews that were carried with children at that year). To be included in the final sample, each case had to meet the following criteria: (a) The child was interviewed as a victim of sexual abuse; (b) The child discussed pain; (c) The interview was the first forensic interview conducted with the child; (d) The child disclosed the abuse during the interview; (e) The child’s first language was Hebrew; and (f) The child did not exhibit any developmental disabilities.

The NICHD investigative interview protocol.

The interviews were conducted by seven trained forensic interviewers with similar professional backgrounds (a degree in social work and at least 18 months of experience as a child forensic interviewer). All interviews followed the National Institute of Child Health and Human Development (NICHD) Protocol (see Lamb et al., 2011), as required in Israel. Using these guidelines allowed us to standardize the interview structure and adhere to best practice.

The NICHD Protocol is a set of structured practical guidelines for forensic interviewers aiming to cover all phases of the interview. The protocol has been found to elicit rich testimonies from children of all ages in response to free-recall invitations (Lamb et al., 2011). It has been implemented in the US, Israel, Sweden, the UK, and Canada, and follow-up studies have systematically indicated significant improvements in the quality of investigative interviews (Cyr & Lamb, 2009; Lamb et al., 2011; Orbach et al., 2000; Sternberg et al., 2001).

The protocol includes three phases. In the initial introductory phase, the interviewer becomes acquainted with the child, explains the ground rules, emphasizes the need to tell the truth, and encourages the child to say “I don’t know” when appropriate. The second phase consists of establishing rapport and introducing the interviewing techniques. When the child appears to be relaxed and comfortable, the interviewer trains the child’s episodic memory using a neutral experience to familiarize the child with the interviewer’s questioning style that emphasizes open-ended questions.

In the final phase, the primary focus of the interview is the incident. Interviewers use mainly open-ended questions that include initial invitations (e.g., “Tell me everything that happened to you from the beginning to the end”), follow-up invitations (e.g., “And then what happened?”), and cued invitations (e.g., “You mentioned the belt; tell me everything you can about that”). Interviewers then employ direct questions (e.g., “When did this happen?”), but only after the open-ended questions appear to have exhausted the child’s recollection. Option-posing questions (e.g., “Did he hit you on the head?”) are asked only when essential forensic information is unavailable and only at the end. Interviewers avoid suggestive questions (e.g., “He made you bleed, right?”). At the end, to help the children relax, interviewers shift the focus of the conversation to neutral topics (e.g., “What are you going to do after the interview?”) (Lamb et al., 2011; Malloy et al., 2011).

Data Analysis

The interviews underwent several interrelated stages of qualitative thematic analysis (Braun & Clarke, 2006). In the first, the researchers identified preliminary ideas. The authors read the first 10 interviews repeatedly, breaking each down into small, textual segments representing discrete units of meaning. The codes thus identified were grouped into initial themes. As the authors continued reading, some codes were removed or revised, and other codes and categories added. In the third stage, themes and subthemes were reviewed, classified, and reclassified (Strauss & Corbin, 1998). Finally, themes were refined and named, and interrelationships suggested (Braun & Clarke, 2006). During this stage, the authors also referred back to the transcripts to retrieve any further information needed to develop the categories (Maykut & Morehouse, 1994).

Trustworthiness was achieved by audit trails and peer debriefing (Lincoln & Guba, 1985; Morse, 2015). The audit trail consisted of documenting how raw data were collected and analyzed, and participants’ direct quotes were attached to all interpretations (Bowen, 2009). The authors also kept personal journals to maintain awareness of influences on their interpretations (Jootun et al., 2009).

Ethical Approval

Because the study was based on files containing highly personal information, the author made an effort to meet the highest ethical standards. The interviews were provided to the authors without names or identifying features of the children, parents, or other people and places involved in the incidents to ensure privacy and anonymity. The study was approved by the Research Board of the Ministry of Welfare in Israel, the Service of Children’s Forensic Interviews in Israel, and the Ethics Committee of Tel Aviv University.

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.

“It Was a Killing Pain Really Deep Inside”: Children’s Description of Pain during Sexual Abuse

The children often used the word pain in their narratives and used the following words repeatedly to describe the intensity of their pain during sexual abuse: very very painful, so painful, burning pain, killing pain, terrible awful pain.

Alongside these vivid descriptions, the children struggled to describe the location of the pain due to the invisibility of their injury: “It was so painful, you could not see the pain, like, I had no injury, but it hurt me for the whole week”; “This pain, it was like a killing pain, but it was not like something you can see, just it is there”; “It’s like I don’t know that it’s painful, there was no external wound, I didn’t have any wound, and… it’s like nothing, I just felt some pain, very very painful, deadly pain and that’s it.”

Although the children struggled to describe the precise location of the pain during the abusive incident, they used the following words repeatedly to describe it: inside, deep, in an unseen place. For example, “it was an inner pain, like I don’t know where, just inside”; “the pain was so deep really really deep, you know like when someone poos from the inside so even deeper than this.”

Regardless of the forensic interviewers’ requests that the children describe how they were touched, the children focused mainly on the experiences of the pain during and found it difficult to elaborate on the perpetrators’ actions and the area in their body where these hurt them:

Interviewer: What was so so painful?

Child: I don’t know, I don’t know, it was terribly awful pain but from the behind like, I don’t know.

“I Was Sitting All Alone Trying to Calm Myself”: Pain Shortly after the Abusive Incident

The children’s narratives provided us with a glimpse on the way they contended with the pain following the abuse. Note that not all children described feeling pain at the time of the abuse; some said that after the abuse they went to sleep and then got up with terrible pain: “He finished and I went to sleep. When I woke up in the morning, I felt burning pain in my tummy—it was terrible!” Many children who did hurt during the abuse described that the pain remained for a week or sometimes several weeks: “it was burning pain for two weeks”; “it was a killing pain for weeks after that.”

The children further described how this continuous pain affected their routine: “I felt every… all week … I could barely speak”; “The pain was so terrible I could not move the whole day after it happened with him, I was just suffering from the pain.” When describing their pain following the abuse the children also referred to additional locations in which they felt pain, mainly in the head, abdomen and legs: “I was suffering all the week from headache and my tummy, it was awful.” Some of the children described those pains as disrupting their daily life routine in sudden bursts, using very strong words. One recurring expression was “killing pain”: “Yesterday I had a killing headache, like a really bad one”; “I was trying to watch TV but suddenly I had like this cramp like I’m going to die in my tummy.”

When sharing these experiences, the children described their loneliness in dealing with inner, unseen, unspoken pain completely on their own: “I was feeling this pain for the all week and I was trying to sit and breathe and to calm myself.” The two most frequent ways of calming themselves down were watching TV and going to sleep: “It was burning pain in my tummy and in my inside and I watched TV and then went to sleep so this pain would go away.” Others described trying to ignore the pain: “I also really really tried not to pay attention, but it hurt so so much… I was in pain for two days, it was hard for me to get up from the couch, from bed, like from everything… it was also painful for me to walk.”

At a certain point in the interview, some of the children switched from the past to describing pain in the present:

I: Tell me more about the pain you felt.

C: It was so so painful that my head was hurting me.

I: Tell me more about it.

C: My head is hurting me right now.

“He Said It Is Painful but Fun”: Pain as Part of the Complex Dynamic with Perpetrator

The children’s narratives reveal a complicated stance whereby the communication of pain by the children intervenes in the dynamic with the perpetrator. Two timelines can be identified: the children’s display of pain during the abuse and their display of pain before or after the abuse.

When the children referred to their display of pain during the abuse, three distinct perpetrator responses were identified: perpetrators who were strangers to the children or their acquaintance who, according to the children`s narratives, responded by ignoring or dismissing the pain, or with punishing expressions of pain. The following narrative provides us with a glance into the dynamic with the perpetrator as the child attempts to communicate the pain, unsuccessfully:

He told me to enter the room… and then I lay on the bed and afterwards he took off his pants and underwear and then after that he…, he…, he…, he… what I said, he…, you know, he…, he…, bent his legs and then he… took that thing where he goes to the toilet and…put it in me where I go to the toilet, in the wee wee, and it hurt me and I said stop, stop, and he didn’t stop and didn’t stop until like…, this is how I think that he held that thing… and then he got down on the bed and he had like… something liquid like, white like, I don’t exactly remember and then ahhh… he…, he left…, he ran to the bathroom and … I heard water, and I got off the bed and put on my panties and my pants, and then he came back, cleaned the bed, and that’s all.

I told him that I’m in pain. I said to him all the time: “It hurts, stop, it hurts.” He told me… one time he told me “calm down,” and then in the other times he did not respond… so I told him: “Stop, I’m in pain, stop.” So he said to me, “calm down.” And then… I like I kept silent and… he continued…

Other strangers and acquaintances responded by punitive violence, or used violence before the abuse as a kind of “preparation” to the coming pain, as illustrated in the following example: “He pushed me on the floor and I started to cry so he started to hit me and it was so painful.” After the incident, the children described being silenced.

These responses of the perpetrators to pain before, during and after the abuse were different when they were family members. In these cases, the children described efforts to reduce or prevent pain or enforcing an abuse relationship dynamic:

I: Was there any time you felt pain?

C: No. He did it gently.

I: Tell me about him doing it gently.

C: Don’t know, because, because, many times he asked me if I’m in pain, I told him no.

This implicit admission by perpetrators that the abuse might be painful to the child is described also in cases where they prepared children for the coming pain:

I: Tell me everything about that time when he tried to penetrate you, but from the beginning…

C: He said it is painful but fun…

This dynamic generated by the perpetrators was evident also after the abuse. In the following example, the child suffered continuous pain after the abuse and shared this with the perpetrator, and the latter tried to communicate to him that the pain was related not to the abuse but to the child’s normal development:

I don’t know why afterwards my butt hurt, after the incident. He told me that “This is, that’s the way it is, now that your body is developing.” I asked him, “Why does this happen?” He said, “‘cause your body is developing, that is why it hurts.”

A related way of normalizing the abuse was to refer to it as an expression of love: “It was painful for me to walk around the house so he asked me why I’m like this and I told him that I’m in pain, so he hugged me and said that this is how love is.”

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.

Forensic and Clinical Implications

The current study holds several forensic implications. A review of the forensic interview transcripts showed that although some of the investigators responded to the child’s report of pain during the interview, this is done within relatively narrow limits. It seemed that the investigators’ main intention is to use the reported pain to infer about the acts of the perpetrators, while the experience of pain in and of itself was insufficiently addressed. Contrarily, the current study sheds light on the opportunity to use reports of pain intensity, location, quality, and duration, as well as its communication as part of the dynamic with the perpetrator, as significant idiosyncratic information, which can enrich and support the children’s testimonies and through this, promote to the prosecution process. Further research is needed to explore ways in which specific questions concerning pain during forensic interviews, such as “From zero to ten, how much pain did you experience?”; “Please tell me about how pain changed during and after this incident,”; “Where in your body did you feel the pain?” may promote the discussion and description of pain by children.

Additionally, the findings of this study hold clinical implications with relation to somatic experiences during and following CSA, and to pain sensations in particular. As such, pain is speculated to be a fundamental ingredient of post-traumatic responses and morbidities. Some clinical endeavors utilize such integrative standpoints (Linehan, 1987; Payne et al., 2015; Shapiro, 2017). However, the current findings stress that integrative perspectives should be further developed and implemented within services providing care and therapy to CSA survivors. As a starting point, practitioners are encouraged to directly target the experience of pain by encouraging children to express and describe their experiences while being abused, as well as their sensations during the intervention. Corroborating and validating the child’s physical pain and suffering may be essential for children who face a profoundly invalidating experience such as CSA. Taken together, further attention should be dedicated to integrative biopsychosocial interventions with survivors of CSA.

Limitations and Future Directions

Several limitations should be considered when interpreting the current findings. The first concerns the interviews from which the narratives were collected. These forensic interviews were carried out for the purpose of a criminal investigation and therefore they did not specifically target the children’s experiences of pain during or after CSA. It is therefore recommended that future studies elaborate on our understanding of CSA-related peritraumatic pain using other methodologies. Second, the findings are based on a relatively small sample. While qualitative research designs normally use small samples, particularly in exploratory studies, and while our goals did not necessarily include generalizability, it is recommended that future investigations include larger and more representative samples.

Third, future investigations should also explore contextual and cultural factors that may intervene in the experience of the body in general and pain sensations in particular, as these were not addressed in the current study. Previous endeavors to understand the experience of the body have postulated that the binary Cartesian perception of the mind–body link, as embraced in Western cultures, views the body as a “vehicle” in service of the “self” (Mehling et al., 2009, 2012). As such, experiences of pain may be viewed as relevant to medical profession, lacking significant information for psychosocial processes. A less dichotomized perception of the mind–body association may therefore lead to a more integrative understanding of trauma and CSA, comprising bodily, emotional, social and cultural factors. Previous research provided mixed findings as to gender differences in pain perception and modulation (Popescu et al., 2010; Soetanto et al., 2006). Additionally, cultural manifestations involving body objectification processes (Calogero et al., 2011; Noll & Fredrickson, 1998) may also intervene in the ways in which children, practitioners, and researchers address and attend to pain in CSA. Future research should address these aspects in the study of CSA peritraumatic pain.

Finally, more attention should be dedicated into uncovering the link between experiences of pain during the abuse, and long-term biopsychosocial responses to CSA. One possible direction would be to examine whether the combination of pain and the way it is embedded within the dynamic with the perpetrator predict differential post-traumatic symptomatology—somatic and mental. Factors such as peritraumatic response to pain sensations during the abuse, the ways children perceive their responses, and the attention dedicated to their pain in clinical and forensic settings should also be accounted for in such investigations.

To conclude, the current study unveils an understudied phenomenon related to the experience of physical pain in CSA. Considering that the experience of the body reflects the initial recognition of self, and self emerges within interpersonal interaction (Iacoboni, 2009; Ogden, 1989), the current study illuminates a novel research realm for understanding the psychosomatic scarring of CSA. Further studies may help disentangle the complex relationships of biopsychosocial factors associated with CSA, providing new directions for empirical, forensic, and clinical endeavors with CSA survivors.

Footnotes

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

ORCID iDs

Noga Tsur

Carmit Katz

Author Biographies

Noga Tsur, PhD, is a faculty member at the Bob Shapell School of Social Work at Tel Aviv University. Dr Tsur is interested in uncovering the ways in which individuals experience their body following trauma. She investigates post-traumatic orientation toward bodily signals, and its link with long-term health-related trauma ramifications. Dr Tsur is especially interested in acute and chronic pain, and the way it is linked with trauma, PTSD and the orientation toward subjective experience.

Carmit Katz, PhD, is a senior faculty member at the Bob Shapell School of Social Work at Tel Aviv University. In her research and practice Dr Katz focus on child maltreatment and deals with issues of children involvement in legal process, family dynamic in cases of child maltreatment and prevention initiatives.

Bella Klebanov, BSW, is a senior social worker in the field of trauma and a research student in the Bob Shapell School of Social Work at Tel Aviv University.

References

Asmundson

G. J. G.

& Katz

(2009). Understanding the co-occurrence of anxiety disorders and chronic pain: State-of-the-art. Depression and Anxiety , 26, 888–901. https://doi.org/10.1002/da.20600

Barth

, Bermetz

, Heim

, Trelle

, & Tonia

(2013). The current prevalence of child sexual abuse worldwide: a systematic review and meta-analysis. International Journal of Public Health , 58(3), 469–483.

Baxt

, Kassam-Adams

, Nance

M. L.

, Vivarelli-O’Neill

, & Winston

F. K.

(2004). Assessment of pain after injury in the pediatric patient: Child and parent perceptions. Journal of Pediatric Surgery , 39(6), 979–983.

Beesley

, Rhodes

, & Salmon

(2010). Anger and childhood sexual abuse are independently associated with irritable bowel syndrome. British Journal of Health Psychology , 15(2), 389–399.

Blount

R. L.

, & Loiselle

K. A.

(2009). Behavioural assessment of pediatric pain. Pain Research and Management , 14(1), 47–52.

Bowen

G. A.

(2009). Document analysis as a qualitative research method. Qualitative research journal , 9(2), 27–40.

Braun

, & Clarke

(2006). Using thematic analysis in psychology. Qualitative research in psychology , 3(2), 77–101.

Calogero

R. M.

, Tantleff-Dunn

S. E.

, & Thompson

(2011). Self-objectification in women: Causes, consequences, and counteractions . American Psychological Association.

Classen

, Koopman

, & Spiegel

(1993). Trauma and dissociation. Bulletin of the Menninger Clinic , 57(2), 178–194.

10.

Cyr

, & Lamb

M. E.

(2009). Assessing the effectiveness of the NICHD investigative interview protocol when interviewing French-speaking alleged victims of child sexual abuse in Quebec. Child Abuse & Neglect , 33(5), 257–268.

11.

D’Andrea

, Ford

, Stolbach

, Spinazzola

, & van der Kolk

B. A.

(2012). Understanding interpersonal trauma in children: Why we need a developmentally appropriate trauma diagnosis. American Journal of Orthopsychiatry , 82(2), 187–200.

12.

Defrin

, Schreiber

, & Ginzburg

(2015). Paradoxical pain perception in posttraumatic stress disorder: The unique role of anxiety and dissociation. The Journal of Pain , 16(10), 961–970. https://doi.org/10.1016/j.jpain.2015.06.010

13.

Drendel

A. L.

, Brousseau

D. C.

, & Gorelick

M. H.

(2006). Pain assessment for pediatric patients in the emergency department. Pediatrics , 117(5), 1511–1518.

14.

Drendel

A. L.

, Kelly

B. T.

, & Ali

(2011). Pain assessment for children: overcoming challenges and optimizing care. Pediatric Emergency Care , 27(8), 773–781.

15.

Drouineau

M.-H.

, Guenego

, Sebille-Rivain

, Vrignaud

, Balençon

, Blanchais

, Levieux

, Vabres

, Picherot

, & Gras-le Guen

(2017). Do abused young children feel less pain? Child Abuse & Neglect , 65, 248–254.

16.

Edwards

R. R.

, Dworkin

R. H.

, Sullivan

M. D.

, Turk

D. C.

, & Wasan

A. D.

(2016). The role of psychosocial processes in the development and maintenance of chronic pain. The Journal of Pain , 17(9), T70–T92.

17.

Finestone

H. M.

, Stenn

, Davies

, Stalker

, Fry

, & Koumanis

(2000). Chronic pain and health care utilization in women with a history of childhood sexual abuse. Child Abuse & Neglect , 24(4), 547–556.

18.

Finkelhor

(2009). The prevention of childhood sexual abuse. The Future of Children , 19(2), 169–194.

19.

Hailes

H. P.

, Yu

, Danese

, & Fazel

(2019). Long-term outcomes of childhood sexual abuse: An umbrella review. The Lancet Psychiatry , 6(10), 830–839.

20.

Häuser

, Kosseva

, Üceyler

, Klose

, & Sommer

(2011). Emotional, physical, and sexual abuse in fibromyalgia syndrome: A systematic review with meta-analysis. Arthritis Care & Research , 63(6), 808–820.

21.

Horowitz

J. D.

, & Telch

M. J.

(2007). Dissociation and pain perception: An experimental investigation. Journal of Traumatic Stress , 20(4), 597–609.

22.

Howell

E. F.

(2014). Ferenczi’s concept of identification with the aggressor: Understanding dissociative structure with interacting victim and abuser self-states. The American Journal of Psychoanalysis , 74(1), 48–59.

23.

Iacoboni

(2009). Imitation, empathy, and mirror neurons. Annual Review of Psychology , 60, 653–670.

24.

Irish

, Kobayashi

, & Delahanty

D. L.

(2010). Long-term physical health consequences of childhood sexual abuse: A meta-analytic review. Journal of Pediatric Psychology , 35(5), 450–461.

25.

Jensen

M. P.

, Gammaitoni

A. R.

, Olaleye

D. O.

, Oleka

, Nalamachu

S. R.

, & Galer

B. S.

(2006). The pain quality assessment scale: Assessment of pain quality in carpal tunnel syndrome. The Journal of Pain , 7(11), 823–832.

26.

R.-R.

, Kohno

, Moore

K. A.

, & Woolf

C. J.

(2003). Central sensitization and LTP: Do pain and memory share similar mechanisms? Trends in Neurosciences , 26(12), 696–705.

27.

Johnson

A. C.

, & Greenwood-Van Meerveld

(2014). Stress-induced pain: A target for the development of novel therapeutics. Journal of Pharmacology and Experimental Therapeutics , 351(2), 327–335.

28.

Jootun

, McGhee

, & Marland

G. R.

(2009). Reflexivity: promoting rigour in qualitative research. Nursing Standard (through 2013), 23(23), 6–42.

29.

Katz

, & Field

(2020). Unspoken: Child-Perpetrator Dynamic in the Context of Intrafamilial Child Sexual Abuse. Journal of interpersonal violence . Advance online publication. https://doi.org/10.1177/0886260520943723.

30.

Katz

, Tsur

, Nicolet

, Carmel

, & Klebanov

(2020). Children’s responses to maltreatment: Key conclusions from a systematic literature review. Trauma, Violence, & Abuse . Advance online publication. https://doi.org/10.1177/1524838020908851

31.

Khandker

, Brady

S. S.

, Stewart

E. G.

, & Harlow

B. L.

(2014). Is chronic stress during childhood associated with adult-onset vulvodynia? Journal of Women’s Health , 23(8), 649–656.

32.

Latremoliere

, & Woolf

C. J.

(2009). Central sensitization: a generator of pain hypersensitivity by central neural plasticity. The Journal of Pain , 10(9), 895–926.

33.

Lamb

M. E.

, La Rooy

D. J.

, Malloy

L. C.

, & Katz

(Eds.) (2011). Children’s testimony: A handbook of psychological research and forensic practice (Vol. 53). John Wiley & Sons.

34.

Lee Peterlin

, Ward

, Lidicker

, & Levin

(2007). A retrospective, comparative study on the frequency of abuse in migraine and chronic daily headache. Headache: The Journal of Head and Face Pain , 47(3), 397–401.

35.

Lincoln

Y. G.

, & Guba

(1985). E. 1985. Naturalistic Inquiry. London, Sage Publications. Contextualization: Evidence from Distributed Teams.” Information Systems Research, 16(1), 9–27.

36.

Linehan

M. M.

(1987). Dialectical behavioral therapy: A cognitive behavioral approach to parasuicide. Journal of Personality Disorders , 1(4), 328–333.

37.

Ludäscher

, Valerius

, Stiglmayr

, Mauchnik

, Lanius

R. A.

, Bohus

, & Schmahl

(2010). Pain sensitivity and neural processing during dissociative states in patients with borderline personality disorder with and without comorbid posttraumatic stress disorder: A pilot study. Journal of Psychiatry & Neuroscience: JPN , 35(3), 177–184.

38.

Macdonald

, Salomons

T. V.

, Meteyard

, & Whalley

M. G.

(2018). Prevalence of pain flashbacks in posttraumatic stress disorder arising from exposure to multiple traumas or childhood traumatization. Canadian Journal of Pain , 2(1), 48–56.

39.

Malloy

L. C.

, La Rooy

D. J.

, Lamb

M. E.

, & Katz

(2011). Developmentally sensitive interviewing for legal purposes. In. Lamb

M. E.

, La Rooy

D. J.

, Malloy

L. C.

, Katz

(Eds.), Children’s testimony: A handbook of psychological research and forensic practice (2nd ed., pp. 1–13). Wiley.

40.

Marmar

C. R.

, Metzler

T. J.

, & Otte

(2004). The peritraumatic dissociative experiences questionnaire. Guilford Press.

41.

Maykut

, & Morehouse

(1994). Qualitative data analysis: Using the constant comparative method. In Beginning qualitative research: A philosophic and practical guide (pp. 126–149). Taylor and Francis.

42.

Mayson

B. E.

, & Teichman

J. M. H.

(2009). The relationship between sexual abuse and interstitial cystitis/painful bladder syndrome. Current Urology Reports , 10(6), 441–447.

43.

McLean

S. A.

, Soward

A. C.

, Ballina

L. E.

, Rossi

, Rotolo

, Wheeler

, Foley

K. A.

, Batts

, Casto

, & Collette

(2012). Acute severe pain is a common consequence of sexual assault. The Journal of Pain , 13(8), 736–741.

44.

Meeus

, & Nijs

(2007). Central sensitization: A biopsychosocial explanation for chronic widespread pain in patients with fibromyalgia and chronic fatigue syndrome. Clinical Rheumatology , 26(4), 465–473.

45.

Mehling

W. E.

, Gopisetty

, Daubenmier

, Price

C. J.

, Frederick

, & Stewart

(2009). Body awareness: Construct and self-report measures. PLoS ONE , 4(5), e5614. https://doi.org/10.1371/journal.pone.0005614

46.

Mehling

W. E.

, Price

, Daubenmier

J. J.

, Acree

, Bartmess

, & Stewart

(2012). The multidimensional assessment of interoceptive awareness (MAIA). PLoS ONE , 7(11), e48230. https://doi.org/10.1371/journal.pone.0048230

47.

Mehta

, Rice

, Chan

, Shapiro

A. P.

, Sequeira

, & Teasell

R. W.

(2017). Impact of abuse on adjustment and chronic pain disability. The Clinical Journal of Pain , 33(8), 687–693.

48.

Merkel

, & Malviya

(2000). Pediatric pain, tools and assessment. Journal of PeriAnesthesia Nursing , 15(6), 408–414.

49.

Moloney

R. D.

, O’Mahony

S. M.

, Dinan

T. G.

, & Cryan

J. F.

(2015). Stress-induced visceral pain: Toward animal models of irritable-bowel syndrome and associated comorbidities. Frontiers in Psychiatry , 6, 15.

50.

Morse

J. M.

(2015). Critical analysis of strategies for determining rigor in qualitative inquiry. Qualitative health research , 25(9), 1212–1222.

51.

Nicol

A. L.

, Sieberg

C. B.

, Clauw

D. J.

, Hassett

A. L.

, Moser

S. E.

, & Brummett

C. M.

(2016). The association between a history of lifetime traumatic events and pain severity, physical function, and affective distress in patients with chronic pain. The Journal of Pain , 17(12), 1334–1348.

52.

Nicolson

N. A.

, Davis

M. C.

, Kruszewski

, & Zautra

A. J.

(2010). Childhood maltreatment and diurnal cortisol patterns in women with chronic pain. Psychosomatic Medicine , 72(5), 471–480.

53.

Noll

S. M.

, & Fredrickson

B. L.

(1998). A mediational model linking self-objectification, body shame, and disordered eating. Psychology of women quarterly , 22(4), 623–636.

54.

Ogden

(2018). The primitive edge of experience . Routledge.

55.

Orbach

, Hershkowitz

, Lamb

M. E.

, Sternberg

K. J.

, Esplin

P. W.

, & Horowitz

(2000). Assessing the value of structured protocols for forensic interviews of alleged child abuse victims. Child Abuse & Neglect , 24(6), 733–752.

56.

Payne

, Levine

P. A.

, & Crane-Godreau

M. A.

(2015). Somatic experiencing: Using interoception and proprioception as core elements of trauma therapy. Frontiers in Psychology , 6, 1–18. https://doi.org/10.3389/fpsyg.2015.00093

57.

Peles

, Seligman

, Bloch

, Potik

, Sason

, Schreiber

, & Adelson

(2016). Sexual abuse and its relation to chronic pain among women from a methadone maintenance clinic versus a sexual abuse treatment center. Journal of Psychoactive Drugs , 48(4), 279–287.

58.

Popescu

, LeResche

, Truelove

E. L.

, & Drangsholt

M. T.

(2010). Gender differences in pain modulation by diffuse noxious inhibitory controls: A systematic review. Pain , 150(2), 309–318.

59.

Probst

B. D.

, Lyons

, Leonard

, & Esposito

T. J.

(2005). Factors affecting emergency department assessment and management of pain in children. Pediatric Emergency Care , 21(5), 298–305.

60.

Putnam

F. W.

(1993). Dissociative disorders in children: Behavioral profiles and problems. Child Abuse & Neglect , 17(1), 39–45.

61.

Putnam

F. W.

(2003). Ten-year research update review: Child sexual abuse. Journal of the American Academy of Child & Adolescent Psychiatry , 42(3), 269–278.

62.

Ross

C. A.

(2005). Childhood sexual abuse and psychosomatic symptoms in irritable bowel syndrome. Journal of Child Sexual Abuse , 14(1), 27–38.

63.

Salomons

T. V.

, Osterman

J. E.

, Gagliese

, & Katz

(2004). Pain flashbacks in posttraumatic stress disorder. The Clinical Journal of Pain , 20(2), 83–87.

64.

Santerre-Baillargeon

, Vézina-Gagnon

, Daigneault

, Landry

, & Bergeron

(2017). Anxiety mediates the relation between childhood sexual abuse and genito-pelvic pain in adolescent girls. Journal of Sex & Marital Therapy , 43(8), 774–785.

65.

Schreiber

, & Galai-Gat

(1993). Uncontrolled pain following physical injury as the core-trauma in post-traumatic stress disorder. Pain , 54(1), 107–110.

66.

Schuder

M. R.

, & Lyons-Ruth

(2004). “Hidden trauma” in infancy: Attachment, fearful arousal, and early dysfunction of the stress response system. In Osofsky

J. D.

(Ed.), Young children and trauma: Intervention and treatment (pp. 69–104). Guilford.

67.

Shapiro

(2017). Eye movement desensitization and reprocessing (EMDR) therapy: Basic principles, protocols, and procedures . Guilford Press.

68.

Sharp

T. J.

, & Harvey

A. G.

(2001). Chronic pain and posttraumatic stress disorder: Mutual maintenance? Clinical Psychology Review , 21(6), 857–877.

69.

Soetanto

A. L. F.

, Chung

J. W. Y.

, & Wong

T. K. S.

(2006). Are there gender differences in pain perception? Journal of Neuroscience Nursing , 38(3), 172–176.

70.

Spiegel

(2003). Hypnosis and traumatic dissociation: Therapeutic opportunities. Journal of Trauma & Dissociation , 4(3), 73–90.

71.

Spiegel

D. R.

, Shaukat

A. M.

, Mccroskey

A. L.

, Chatterjee

, Ahmadi

, Simmelink

, Oldfield

E. C.

, Pryor

C. R.

, Faschan

, & Raulli

(2016). Conceptualizing a subtype of patients with chronic pain: The necessity of obtaining a history of sexual abuse. The International Journal of Psychiatry in Medicine , 51(1), 84–103.

72.

Sternberg

K. J.

, Lamb

M. E.

, Davies

G. M.

, & Westcott

H. L.

(2001). The memorandum of good practice: Theory versus application. Child Abuse & Neglect , 25(5), 669–681.

73.

Stoltenborgh

, Van Ijzendoorn

M. H.

, Euser

E. M.

, & Bakermans-Kranenburg

M. J.

(2011). A global perspective on child sexual abuse: Meta-analysis of prevalence around the world. Child Maltreatment , 16(2), 79–101.

74.

Strauss

, & Corbin

(1998). Basics of qualitative research techniques . Sage Publications.

75.

Tsur

(2020). “My own flesh and blood”: The implications of child maltreatment for the orientation towards the body among dyads of mothers and daughters. Child Abuse & Neglect , 104, 104469.

76.

Tsur

, Defrin

, Lahav

, & Solomon

(2018). The traumatized body: Long-term PTSD and its implications for the orientation towards bodily signals. Psychiatry Research , 261, 281–289. https://doi.org/10.1016/j.psychres.2017.12.083

77.

Tsur

, Shahar

, Defrin

, Lahav

, & Ginzburg

(2017). Torturing personification of chronic pain among torture survivors. Journal of Psychosomatic Research , 99, 151–161. https://doi.org/10.1016/j.jpsychores.2017.06.016

78.

Ulirsch

J. C.

, Ballina

L. E.

, Soward

A. C.

, Rossi

, Hauda

, Holbrook

, Wheeler

, Foley

K. A.

, Batts

, & Collette

(2014). Pain and somatic symptoms are sequelae of sexual assault: Results of a prospective longitudinal study. European Journal of Pain , 18(4), 559–566.

79.

Van der Kolk

B. A.

(2015). The body keeps the score: Brain, mind, and body in the healing of trauma . Penguin Books.

80.

Van der Kolk

B. A.

(1998). Trauma and memory. Psychiatry and Clinical Neurosciences , 52(S1), S52–S64. https://doi.org/10.1046/j.1440-1819.1998.0520s5S97.x

81.

Van der Kolk

B. A.

(2017). Developmental trauma disorder: Toward a rational diagnosis for children with complex trauma histories. Psychiatric Annals , 35(5), 401–408.

82.

Van der Kolk

B. A.

, & Fisler

(1995). Dissociation and the fragmentary nature of traumatic memories: Overview and exploratory study. Journal of Traumatic Stress , 8(4), 505–525.

83.

Van Meijel

E. P. M.

, Gigengack

M. R.

, Verlinden

, van der Steeg

A. F. W.

, Goslings

J. C.

, Bloemers

F. W.

, Luitse

J. S. K.

, Boer

, Grootenhuis

M. A.

, & Lindauer

R. J. L.

(2019). The association between acute pain and posttraumatic stress symptoms in children and adolescents 3 months after accidental injury. Journal of Clinical Psychology in Medical Settings , 26(1), 88–96.

84.

Wilkie

D. J.

, Holzemer

W. L.

, Tesler

M. D.

, Ward

J. A.

, Paul

S. M.

, & Savedra

M. C.

(1990). Measuring pain quality: Validity and reliability of children’s and adolescents’ pain language. Pain , 41(2), 151–159.

85.

Woolf

C. J.

(2011). Central sensitization: Implications for the diagnosis and treatment of pain. Pain , 152(3), S2–S15.

86.

Woolf

C. J.

, & Salter

M. W.

(2000). Neuronal plasticity: Increasing the gain in pain. Science , 288(5472), 1765–1768.