The Impact of Critical Life Points and Events for Survivors of Institutional Child Sexual Abuse: Understanding Trauma and the Role of Compensation in Recovery

Abstract

Although the impact of child sexual abuse (CSA) is well documented in the international literature, little is known about the critical points of recovery across the life course for survivors of institutional CSA. The aim of this study was to identify critical points, or events across the life course that may increase, or decrease, a survivor’s vulnerability to the complex traumatization of institutional CSA (ICSA). The sample consisted of two hundred and forty-eight witness statements extracted from the 56 publicly available case studies presented to the Australian Royal Commission into Institutional Responses to Child Sexual Abuse during 2013–2016 (Commonwealth of Australia, 2017). A content analysis and thematic coding of the statements identified seven main themes in the witness statements (Gender, Organization, Triggers, Trauma, Mental Health, Intervention and Compensation), that appeared to be critical events across the life course. The themes were transformed into variables for further analysis using SPSS. Significant Likelihood Ratios were found between associations with the organization where the abuse occurred and between triggers and breastfeeding/sensory, breast feeding/childcare, emotional and physical distress, and mental health (p < 0.01). Significant associations were also found between receiving compensation for the CSA and triggers, trauma, breast feeding-sensory and childcare (p < 0.05) and gender and breast feeding (p < 0.05). Overall, the findings showed that triggers can be random across the life course occurring mainly through indirect association, or in situations that evoke memories of the CSA, and that receiving compensation can assist survivors in their recovery journey. The findings also indicate the need for health care professionals to be aware of the critical points in a CSA survivor’s recovery and how triggers may impact on their mental welling throughout the life course.

Keywords

institutional sexual abuse child sexual abuse revictimization and recovery

It is well established in the literature that the intensity and nature of the effects of child sexual abuse (CSA) varies greatly amongst child and adult survivors as they move through their life course (Fergusson, et al., 2013). Evidence drawn from a meta-analysis of population-based studies of survivors undertaken by Lindert, et al. (2014) found both memories and follow-on effects such as re-triggering of trauma associated with memories of the abuse, may occur at any stage in the individual’s life course (Alaggia et al., 2019; Anderson & Hiersteiner, 2008; Blunden et al., 2021; Commonwealth of Australia, 2017). Early research on survivors of clergy perpetrated CSA (Fogler et al., 2008) suggests that important developmental tasks, particularly in early adolescence, can be significantly compromised due to CSA, altering the trajectory of the survivors’ life course in terms of relationships, spiritual and social development. This finding led to an increase in studies exploring the impact of CSA on self-identity and on-going re-triggering of trauma throughout survivors’ life course (Easton et al., 2016).

Jacobs-Kayam and Lev-Wiesel (2019) and Alaggia et al., (2019) found CSA survivors can be re-traumatized both mentally and physically when encountering triggers associated with past traumatic events. Foster and Hagedorn (2014) noted many survivors experience ongoing trauma and report being fearful for both their own safety and the safety of their children when exposed to a known perpetrator. Sanderson (2006) reported survivors are triggered when their own children reach the age they were when abused.

Greenberg (2015; 2010) identified that emotional responses are automatic biologically based tendencies that act as a re-traumatising trigger. Seemingly innocuous stimuli, such as a smell or an act of intimacy, have been found to evoke memories and associations with sexual abuse for survivors and regularly trigger negative effects (Briggs, 1994; Malmo & Laidlaw, 2010). Likewise, a study of survivors of clergy perpetrated CSA undertaken by Easton et al. (2016) found exposure to the church where assaults had occurred prompted further distress and anger. Other studies (Leeners et al., 2016; Wood & Van Esterik, 2010; Robohm & Buttenheim, 1997) found triggers can be gender specific, for example, female CSA survivors report that childbirth, breast feeding, or invasive or intrusive medical procedures are potential triggers for some women.

In terms of relationships, it is widely acknowledged that survivors of ICSA can experience difficulties forming and maintaining relationships (Carr et al., 2009; Rossetti, 1995). Multiple researchers found interpersonal relationships and sexual difficulties in both male and female survivors as well as an increase in the level of distress, a sense of shame and self-blame (Whiffen & MacIntosh, 2005; Vaillancourt‐Morel et al., 2016). More specifically, Wolfe et al. (2006) found survivors commonly report sexual problems in adulthood due to sexual acts triggering the survivor’s memories of abuse, thereby creating difficulties in maintaining adult relationships.

While several studies (Conte & Schuerman, 1987; Whiffen & MacIntosh, 2005) found that family dysfunction and distress can impact on outcomes for CSA survivors, others strongly point to the family environment as being an important mediator for both support and additional distress. Historically, disclosure of CSA was often met with scepticism, making it a particularly vulnerable time for survivors (Alaggia, 2004). Furthermore, disclosure of the abuse by children or adult CSA survivors to others can be a critical point in the survivor’s recovery. Other studies (Anderson & Hiersteiner, 2008; Chouliara, et al., 2014) identified that responses to disclosure can enhance or hinder recovery depending on the level of survivor validation and attribution of blame to the perpetrator.

Alongside the impact of disclosure are the effects of CSA in adulthood which may vary according to age, as some younger adults may not recall the CSA, repress recall or minimise the effects of that abuse (O’Leary & Barber, 2008). Additionally, Alaggia et al. (2019) identified a portion of children and adolescents attempt to disclose covertly through behaviours such as drug use or suicidal gestures. O’Leary et al. (2010), discovered that some survivors aged between 30- 40 years, reported more mental illness than is normally expected, which may in turn have delayed disclosure of the abuse. When mental illness, drug use or suicide attempts are not followed up with support, a spiral of distress can develop (Alaggia et al., 2019).

In support Easton (2014), established that the quality of the response to disclosure, the years it takes to disclose along with other unrelated childhood adversities, have been shown to be significantly associated with greater levels of mental distress, as was the case for male survivors of clergy perpetrated CSA. For a minority of adults who were sexually abused in childhood and did not receive counselling support at the time of disclosure, psychological issues and abuse-specific coping behaviours developed at a later stage (Steel, et al., 2004; O’Leary, 2009).

For many adult survivors, the act of disclosure and discussion related to the sexual abuse may need to be repeated as the survivor moves through the life course particularly when forming new relationships or receiving counselling (O’Leary & Barber, 2008). While each repetition can prompt a re-triggering of trauma or distress, it may also be an opportunity for validation and personal growth (Tener & Murphy, 2015). Capella et al., (2018) and Alaggia et al. (2019) support the findings of Tener and Murphy (2015) and suggest that triggers can act as a key turning point leading to recovery and the building of coping and resilience skills that result in post-traumatic growth.

Prati and Pietrantoni (2009) found the exposure to therapeutic and social support, alongside the formation of positive beliefs and meaning about the trauma, can build resilience and recovery in survivors whereas Briere and Scott (2014) found the process of recovery is non-linear, and many survivors experience post-traumatic growth along with re-triggering and trauma-related regression. Shakespeare-Finch and De Dassel (2009) also noted how both post-traumatic growth and mental distress from triggers can co-exist.

The role of compensation in survivors healing is not well researched. Some research suggests both negative and positive impacts associated with compensation, however, there is an overall assumption it may improve survivor well-being (Blunden, et al., 2021). An outcome of the RCIRCSA (2017) was the suggestion that compensation by institutions could have a positive impact on survivor healing, however, the process to seek financial payment through redress, compensation, or civil action can add to the survivor’s trauma in many cases. Although details of the process and the final pay outs are usually withheld, the limited information that is available suggested there were large disparities regarding the payment outcomes survivors of CSA receive (Daly & Davis, 2021). As a result, the RCIRCSA (2017) recommended for better, independently administered options and better systems be put in place for survivors to seek redress. In Australia a ‘Redress’ scheme has been established by the Federal Government to better streamline processes, however, preliminary results suggest there are still numerous challenges (Kruk, 2021). Results clearly showed the need for further research on such schemes.

The paucity of empirical knowledge about the critical life points and events for survivors of institutional CSA limits the professional assistance currently offered to survivors. For practitioners, across a range of professions, gaining an understanding of the critical points that cause ongoing distress across the survivor’s life course will assist with recovery as well as the design and application of future therapeutic interventions to help decrease survivors’ vulnerability to the ongoing effects of child sexual abuse and promote post traumatic growth.

While research has identified that many CSA survivors suffer ongoing re-traumatization associated with the re-triggering life events, few studies have specifically examined the critical points that impact on the life course of survivors of ICSA.

The review to date of the current state of knowledge points to the need for further research that looks beyond the effects of ICSA during the life course. More understanding of the critical points that influence positively, and negatively, survivor experiences and wellbeing is required. Moreover, practitioners’ and policy makers need to be able to identify these critical points in order to create better responses for survivors.

This study seeks to advance the knowledge base in relation to survivors of institutionalized sexual abuse by: (1) identifying critical key points over the life course that can trigger a trauma response; (2) determining statistical significant associations between identified triggers and the impact on a survivor’s mental well-being; (3) gaining a better understanding how some critical points (such as receiving formal compensation) may promote positive contribution to their well-being and recovery; (4) increasing awareness among helping professionals of how triggers may impact on a survivors’ mental welling throughout the life course. The CSA survivor witness statements presented to the Australian Royal Commission Institutional Responses to Child Sexual Abuse during 2013–2016 have provided a rich source of data to explore these questions.

Methods

Data Source

The study was based on data obtained from publicly available case studies presented to the Australian Royal Commission Inquiry into Institutional Responses to Child Sexual Abuse during 2013–2016 (http://www.childabuseroyalcommission.gov.au). Initial inspection of the case studies was undertaken to identify witness statements. Ten of the 56 case studies retrieved from the website were recommendations for organizational review and were excluded from the study. Of the 46 remaining case studies a further 10 were excluded as they contained insufficient information in the witness statements. Figure 1 outlines the retrieval process of the 248 witness studies included in the sample. Applying a content analysis to the deidentified witness statements allowed for the data extracted to be analysed using both qualitative and quantitative analysis. Witness statements included information about the context in which sexual abuse occurred as well as an exploration of survivor experiences in how it impacted on their life and their coping strategies. This included significant points in their journey that impacted on their wellbeing.

Figure 1.

Flow diagram of Retrieval of Case Studies Presented to the Australia Royal Commission Inquiry into Institutional Child Sexual Abuse 2013–2016.

Ethical Approval

The study had approval from the Griffith University Human Research Ethics Review Committee (GU Ref No: 2017/284)

Data Collection

Data collection was carried out manually by two experienced data reviewers. The first reviewer conducted a detailed line-by-line analysis of the information contained in the case studies to identify any major themes evident in the witness statements and developed a coding frame to capture the analytically significant features of the data. As described by O’Connor and Joffe (2020), this allowed for a list of codes to be established, defined, and organized into categories. Thematic coding of the data extracted during the content analysis was then undertaken by the same reviewer by breaking down the themes into manageable coded categories to assist identification of possible critical events in the life course (as reported by the CSA survivors) and the impact on their recovery. Once saturation had been reached and final codes were assigned, the data and coding were then reviewed by the second reviewer using the same process.

Both reviewers then separately scrutinized all the final codes and identified key themes (Gender, Organization, Trigger, Trauma, Mental Health, Intervention and Compensation) that may impact on recovery from CSA. Based on this process employed to identify the final themes, the close agreement between the two reviewers in terms of data extraction and the thematic coding process, inter-rater reliability was assessed as being high according to Gwet’s (2014) guidelines.

Categorical variables

The identified themes were coded, converted into the quantitative categorical variables. The data was analysed using IBM SPSS Statistics (Version 26) predictive analytics software. As demographic characteristics were not recorded in the case studies gender was assumed from the responses contained in the witness statements and were coded as female=1, male=2, not known=3.

Results

Descriptive Analysis

Responses in the case studies indicated 207 male (83.5%) and 37 (14.9%) female witnesses presented statements to the RCIRCSA. It was not possible to identify the gender of four witnesses.

A frequency distribution provided key characteristic information for each variable. As Table 1 shows the CSA occurred three times more frequently (63%) in a religious organization and while a variety of experiences can trigger recall of the abuse, 39.5% of the witnesses reported having Flashbacks triggered by either seeing a perpetrator, reports in the media, or being in location where the CSA had occurred. Breastfeeding, childcare or being touched triggered a trauma response for 25% of witnesses. Almost 91% reported having mental health problem (ranging for psychiatric diagnoses, attempted suicides, substance abuse and relationship issues). In terms of intervention 15.7% were admitted to inpatient care, 52% attended counselling, 50.8% had received compensation with 6% of claims still being processed and 49.2% had either not claimed, or their claim had been rejected.

Table 1.

Frequency Distribution of Converted Themes to Categorial-Sub-category variable (N=7).

Variable	Sub-categories	(%)
Organizations (% distribution of Perpetrators)	Religious orders	63.0
	State wards	18.5
	Medical/Police	6.9
	Community organizations	5.6
	Defence force	5.6
	Criminal justice system	0.4
Triggers	Perpetrator-Contact/Seeing/Media	18.1
	Breast feeding/Childcare	12.9
	Sensory-being touched	12.1
	Social interaction/Trust issues	10.9
	Relationship issues	8.1
	Intrusive thoughts	6.9
	Violence to self or others	2.0
	Not reported	29.0
Trauma emanating from triggers	Flashbacks	39.5
	Emotional/Physical reaction	21.0
	Distress	7.3
	Social/Relationship/Trust issues	3.6
	Memories of CSA	3.2
	Sensitivity re childcare	2.0
	Sensory/being touched	1.6
	Employment issues	1.6
	Not reported	20.2
Mental health problems	Diagnosis	30.2
	No formal diagnosis	5.2
	Mental health issues	21.8
	A&D4	10.5
	Suicide	23.5
	Relationship problems	4.8
	Not reported	4.0
Intervention received	MH Admission	15.7
	GP/Medicated	2.0
	Counselling	52.0
	No counselling	10.9
	Not reported	19.4
Compensation	Religious order	29.0
	Agency	4.8
	Government scheme	11.0
	Processing	6.0
	No claim/Not reported	49.2

Likelihood Ratios

From an initial descriptive analysis of the variables totals, means and standard deviations significant skewness and/or kurtosis within each of the variables were identified. Given the abnormal distribution associated with the skewness of the data non-parametric tests were utilized for analysis. Pearson’s chi-square test of contingencies (with α = .05) were used to determine relationships between the themes. Due to violation of some of the chi-square tests associations were concluded from Likelihood Ratios. Cramer’s V was used to measure the strength of any associations between the variables.

As presented in Table 2, positive likelihood associations derived from the crosstabulation analyses were found to be present between 15 pairs of variables with significant effect sizes determined from Cramer’s V and p values.

Table 2.

Significant Associations and Strengths Between Critical Factors Affecting of Survivors Institutional CSA.

Significant Associated Variables	Likelihood Ratio (LR)	Effect Size (Cramer’s V)
Trigger/Breast feeding-sensory	314.28	.000 **
Trauma/Emotional physical distress	237.13	.000 **
Trigger/Breastfeeding-childcare	166.90	.000 **
Trigger/Trauma	64.38	.000**
Trauma/Mental health	52.49	.028*
Trigger/Organisation	47.83	.017*
Mental health/Organisation	35.23	.000*
Trauma/Breast feeding-sensory	26.27	.024*
Mental health/Emotional physical distress	19.91	.000*
Trauma/Breast feeding-childcare	18.24	.004**
Compensation/Trigger	16.40	.011*
Compensation/Trauma	16.13	.040*
Compensation/Breast feeding-sensory	11.22	.004**
Compensation/Breast feeding-childcare	6.01	.016*
Gender/Breast feeding-childcare	4.15	.028*

NB: p<.0.01 ** p<.0.05 *.

Significant Associations and Effect Sizes

Several statistically significant likelihood associations (LR’s) were found between all seven of the study’s main themes and are presented in Table 2. As noted, large likelihood associations with significant effect sizes were identified between the variables triggers with breast feeding—sensory, trauma response with emotional, physical distress, breast feeding-childcare and between triggers and trauma (LR = 314.28–64.38: p < 0.01). The association between trauma and mental health was also statistically significant (LR = 52.46; p<0.05).

Medium strength associations with significant effect sizes were found between triggers and organizations, trauma, and breast feeding (LR = 47.83–26.27I; p < 0.05), mental health and organizations (LR = 35.23; p < 0.05). While medium to smaller associations were determined between mental health problems and emotional/physical distress and trauma and breastfeeding, the effect sizes were significant (LR = 19.19–18.24; p < 0.01).

Smaller likelihood associations with statistically significant effect sizes were also found between the following variables: receiving compensation for CSA with breast feeding-sensory (LR = 11.22; p < 0.01), triggers, trauma, and breast feeding-childcare and gender and breast feeding and childcare (LR = 16.40–4.01; p<0.05).

Discussion

This study set out to identify critical life points and events across the life course that could potentially increase a survivor’s vulnerability to complex re-traumatization of institutional CSA. Many of the results were intuitive and affirm and expand the existing evidence base. Although determining significant likelihood associations between triggers and trauma responses was not unexpected, nor was the impact of institutional CSA on a survivors’ mental health the findings do expand the knowledge on environments or situations that can trigger survivors of institutional CSA into a negative emotional response.

The key additional, and important finding, arising out of this study was the survivors’ identification of the impact of compensation on their mental wellbeing. This finding is of particular interest as there are substantial gaps in the literature in understanding the impact of compensation and redress on survivor wellbeing. Often this is because such claims and follow-up with recipients is often kept private by way of legal agreement (Daly & Davis, 2021). This finding does raise questions about the mediating role that compensation may have on a survivors’ recovery journey. As noted by Kruk (2021) understanding the impact of redress on survivors is an important public policy issue so that suitable schemes can be established.

Receiving compensation is not just about monetary gain, it’s about validation that a crime has been committed against a child. It may also provide financial assistance that will enable them to gain access to much needed intervention and support services. In this way compensation can make a difference in recovery from the ongoing devasting effects of CSA.

This has been described as a ‘therapeutic jurisprudence’ by Feldthusen et al. (2000) where the process of redress and compensation is a repudiation of guilt, shame and responsibility by placing the burden on the perpetrators and those who failed to protect the child. Such an official acknowledgement enables survivors to consider a return to ‘ordinary life’, with a restored capacity for life and relationships. This places the survivor in a position to be honoured in any justice process regardless of its restorative or redress characteristics (Herman, 2005).

Findings in this study on compensation are amongst the first to reveal its role in recovery, however, additional research regarding the nature of compensation or redress requires further discreet inquiry to understand the likely multivariable factors involved.

Clinical Implications

From a clinical point of view the characteristics of institutional CSA and the possibility of further traumatization need to be fully considered. In this study the critical events associated with the CSA were either emotional responses to reminders via media reports about the institution, seeing the perpetrator, intrusive touch or actions that reminded the survivor of the abuse.

Awareness of these ‘triggers’ is required in mainstream services such as medical and personal services. Care providers need to be able to recognize that such occurrences could spark trauma responses. This requires more attention to minimum educational standards for health care professions so that they can be more ‘trauma aware’ (Spratt & Kennedy, 2021). Active training and audits of mainstream services trauma aware and informed practises is needed.

Other triggers, such as difficulties in social or personal relationships and parenting responsibilities, or exposure to other trauma were also points of traumatization and/or recovery and are also worthy of continuing education. Increasing awareness and understanding that any health care professional is likely to encounter survivors who have experienced CSA can assist in the prevention of revictimization.

The RCIRCSA (2017) recommendations suggest that trauma informed approaches offer the most potential for effective responses to CSA survivors. However, it is important to consider the ongoing debate in the literature as to how screening processes, or prompting a disclosure of CSA, should be managed. Finally, the role compensation can play in a survivors’ recovery requires further acknowledgement by clinicians especially when considering this in the context of therapeutic jurisprudence.

Strengths and Limitations

The data was collected retrospectively from case studies presented to the RCIRCSA during 2013–2016. While the findings do enrich our understanding of the range of emotions and responses elicited by triggers, there some methodological and sampling limitations. A significant limitation is that the authors did not have input into the questions asked by the RCIRCSA nor could clarification be sought to the responses made by the witnesses. This means while some witnesses did not specify a response to a situation, due perhaps to difficulties in articulating emotional experiences to a panel, it does not mean they didn’t experience it. However, there was a general pattern in how case studies were conducted by the RCIRCSA, and the way witnesses gave statements. This provided some consistency across the data used for this study. The demographic data (age, gender, racial, ethnic and sexual orientation) was provided in witness statements and in few cases was not fully covered. Limitations of this secondary research data need to be tempered with the substantial knowledge gap in literature on this topic. Thus, this study is one of the few to look at critical points life points for survivors of CSA.

Due to the skewness and abnormal distribution of the data in this sample standard statistical analysis were not able to be undertaken. This reduced the sensitivity and robustness of the findings.

Finally, we do acknowledge that methodologically there are challenges in linking triggering events uniquely linked to CSA as per opposed to stress or anxiety occurring simply in response to unpleasant stimuli. However, despite these concerns this study has shown there is evidence that there are critical points in survivors’ journey that warrant broader consideration and exploration. While the study is supported by findings in other studies reported in the literature, it also brings to the fore the need to consider the role of compensation in a survivor’s recovery journey.

Despite these limitations these findings can assist in developing clinical and educational interventions with survivors of CSA by increasing their sense of entitlement to respectful and sensitive service delivery and ultimately reduce their risk of further traumatization.

Conclusion

There are many factors that influence survivors of institutional CSA recovery that must be negotiated in the context of unexpected and often uncontrolled exposure to triggers. These can serve to remind survivors of the human rights violation and failure of an institution to protect a child from harm. Such experiences also highlight survivor resilience and post-traumatic growth.

There is increasing international attention about how iconic institutions such as the Catholic Church and States can be held accountable and offer redress to survivors of child sexual abuse. This study has identified factors that may impact over the life course of survivors of institutional CSA. It has shown that while triggers can be random and occur at any time, they do mainly happen through indirect association, or in situations that are associated with child abuse events(s). Importantly the study provides some preliminary insight into the role that compensation and redress may play on acknowledging the ongoing impact as well as improving the lives of survivors. The interplay of critical points in recovery and the role of compensation, redress and jurisprudence offers some future direction for both research and practice in empowering survivors of child sexual abuse.

Future Research

Considering institutional child sexual abuse scandals in Australia and across the world there is a need to better understand trigger and critical points in a survivor’s recovery. Future studies need to be designed to gain more in-depth understandings of the critical points across the life course that have the potential to further traumatize survivors of institutional CSA. More empirical evidence about successful clinical interventions that can be employed to assist survivors through difficult life event situations and the place of compensation in recovery is need. Finally, research into the role compensation plays in recovery for survivors of ICSA and how redress can be best achieved in the least traumatic way is urgently needed.

Footnotes

Acknowledgements

The courage of the survivors who made statements to the Royal Commission.

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 iD

Lynne Briggs

Author Biographies

Lynne Briggs, PhD, is an Associate Professor at Griffith University. Her research includes national and international mixed method studies in mental health outcomes, exploring whether demoralization may provide a more relevant diagnosis than clinical depression, the impact of child sexual abuse on adult women survivors, refugee women, gender-based violence and interventions in disasters.

Patrick O’Leary, PhD is a Professor and Co-Lead of the Disrupting Violence Beacon at Griffith University. He is internationally recognized researcher with expertise in domestic violence/gender-based violence, child protection, long-term impact of child sexual abuse (especially for men), social work, and socially excluded young people.

Janine Grove, MSW, is a Mental Health Clinician. Her experience includes working on several research projects that have explored recovery for survivors of institutional child sexual abuse, housing for people with disabilities, outcome of treatments for breast cancer survivors, risk taking for people with dementia and the effect of stress on the hippocampus.

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