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Child sexual abuse (CSA) is any sexual interaction (stimulation or observation) between a child and an adult or older child. It usually involves direct physical contact, inappropriate touching, kissing, fondling, rubbing, oral sex, or penetration of the vagina or anus. Producing child pornography or forcing children to watch sexual materials or acts are also included as child sexual abuse. Perpetrator often use deceptions, threats, play, and other coercive methods to lure the child and keep their silence (Deblinger, n.d.; What is child sexual abuse?, n.d.).

Prevalence

According to the __CDC__ (2010), one in five women and one in 71 men has been raped in their lifetime. For sexual violence other than rape, CDC reported lifetime prevalence of one in two women and one in five men.

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For children under the age of 18, approximately one in four girls and one in six boys are sexually abused (__Department of Justice, 2015__). In 2012, 62,939 cases of child sexual abuse were reported (Child Maltreatment, 2012).
Women are more likely to report CSA than men and are also more like to report penetrative abuse and to be abused by a family member (as cited in Zwickl & Merriman, 2010).




Risk Factors for CSA (Putnam, 2003)

  • Gender (females are more likely)
  • Age
  • Disability
  • Absence of one or more parents
  • Presence of stepfather
  • Intergenerational sexual abuse













Effects of CSA


unnamed.gifCSA victims experience feelings of fear, shame, betrayal and powerlessness. In addition to the experience of betrayal caused directly by the offender, a child may experience further betrayal if he/she discloses the abuse and he/she is not believed by the adult confided in. This in turn reinforces the sense of powerlessness (Træen and Sørensen, 2008). The cumulative effects of these formative traumatic experiences are often deleterious to attachment (Zala, 2012), emotional development, and self-perception (Træen and Sørensen, 2008). CSA victims may see themselves as unlovable, and others as potentially dangerous (Zala, 2012).

Short-term Effects


Not all children exhibit symptoms of sexual abuse. Some are asymptomatic, which often results in delayed disclosure (__Department of Justice, 2015__). However, many show initial behavioral changes that can be indicators to adults that a child has been sexually abused. Bed-wetting, thumb sucking, and doll destruction are all examples of regressive behaviors resulting from child sexual abuse. In addition, inappropriate sexual behaviors like early sexual interest, inappropriate sexual knowledge, and sexual acting out are also indicators of child sexual abuse (Hornor, 2010; Tyler 2002; Walsh & DiLillo, 2011). Other short-term psychological effects include, but not limited to, sleep disturbances (Noll, Trickett, Susman, & Putnam, 2006; Steine et al., 2012) and poor performance at school (Walsh & DiLillo, 2011).
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Long-term Effects

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Child sexual abuse found to be associated with (Nasim & Nadan, 2013; Cohen et. al, 2004; Putnam, 2003):
                  • Depression
                  • Re-victimization in adulthood
                  • Suicidality
                  • Sexual promiscuity
                  • Anxiety
                  • Substance abuse
                  • Borderline personality disorder
                  • Somatization disorder
                  • Posttraumatic stress disorder (PTSD)
                  • Dissociative identity disorder
                  • Bulimia nervosa
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Depression is amongst the most common effects of child sexual abuse. Research states that 43-67% of victims meet the diagnostic criteria of depression (Walsh & DiLillo, 2011). Combined with high levels of anxiety, substance abuse is a common way to escape and cope with the depression and anxiety (Hornor, 2010; Walsh & DiLillo, 2011). A study performed by the National Institute on Drug Abuse (Zickler, 2002) found that child sexual abuse is strongly associated with substance abuse, compared with depression, anxiety, and other psychiatric disorders.

Factors that Influence Severity of Effects (Watson & Halford, 2010)

  • Degree of physical intrusion
  • Victimization by family member as opposed to non-relative or stranger
  • Psychological coercion tactics
  • Age at which abuse began
  • Duration of abuse
Incest has been found to result in serious, long-term psychological dysfunction and disrupted attachment.
http://www.nctsn.org/sites/default/files/assets/pdfs/QAChildSexualAbuseED103007.pdf
http://www.nctsn.org/sites/default/files/assets/pdfs/QAChildSexualAbuseED103007.pdf


Parent-Child Relationship Effects


Parenting is one of the most important mechanisms by which a child victim may recover and adjust. However, as previously mentioned, CSA can lead to emotional and behavioral challenges in children, factors which negatively impact parent-child relationships (Santa-Sosa, Steer, Deblinger & Runyon, 2013).
Non-offending mothers of CSA victims report higher levels of distress and depression, as do mothers who themselves are CSA victims (Walsh & DiLillo, 2011; Santa-Sosa, Steer, Deblinger & Runyon, 2013). Depression in mothers is shown to negatively impact parenting. Maternal depression is associated with withdrawal, less consistency in parenting, harsh discipline, and less engagement. However, these factors may be moderated by the marital relationship, for example, if the father supports the mother and helps with parenting (Santa-Sosa, Steer, Deblinger & Runyon, 2013).
In the way that the distress and mental health manifestations of CSA are reciprocal between child and parents, CSA inflicts what is sometimes referred to as “systemic trauma” (Kilroy, Egan, Maliszewska & Sarma, 2014).

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Couples Relationships

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Women who are victims of CSA have a rate of marital separation that is double that of non-victims (Watson & Halford, 2010). Difficulty with trusting her intimate partner may occur, and increased triangulation with family of origin is often found with women victims of CSA (Trute, Docking & Hiebert-Murphy, 2001).

Male victims of CSA also face challenges trusting partners, and may also experience avoidance of emotional or physical intimacy; however, they face an additional conflict when negotiating the socialized expectancies of males as powerful and less vulnerable (Kia-Keating, Sorsoli & Grossman, 2010). In one qualitative study, male victims have expressed that male victimization is underacknowledged in society, but that it had highly impacted their emotional and sexual relationships in adulthood (Gill & Tutty, 1999).

Both male and female victims exhibit increased contempt and defensiveness in relationships (Walker, Sheffield, Larson & Holman, 2011).

Many adult survivors of CSA use “emotional avoidance” and may have negative associations with emotional or sexual intimacy, particularly when the perpetrator was a close friend or family member. This may lead to difficulty with entering into committed relationships (Watson & Halford, 2010).

Male partners of female CSA survivors experience “secondary trauma,” including higher reports of individual distress and symptoms of trauma (Nelson & Wampler, 2002). Most survivors of CSA do not report as children; many first disclose their victimization to their intimate partners later in life (Miller & Sutherland, 2014). If the partner reacts to disclosure in a way that dismissive or nonprotective, the victim may also be retraumatized (Nasim & Nadan, 2013).

Couples with history of CSA receiving sex therapy reported more negative effect on dyadic adjustment (both dyadic satisfaction and dyadic consensus) (Berthelot et al. 2014). In this study with 218 adults, all clinically depressed clients were CSA survivors. How does depression affects sexual functioning?

Partners In Healing (Miller & Sutherland, 2014)


This article discusses the significant potential for either healing or reinforcement of negative effects that a partner may have through their relationship and responses to a person who is a survivor of CSA. Because CSA victims are more prone to sexual dysfunctions in adulthood, this article proposes that the partner should be involved in therapy for CSA survivors as they are pivotal to the outcomes for therapy.
According to the article, many adult survivors first report their abuse as adults to their partner, and that it is a minority of children who disclose abuse at the time of its occurrence. The authors state, "It is naive and limiting to view the process of recovery as solely an individual journey" (pg. 99). In taking this systemic perspective, part of what the authors suggest is that through therapy, the partner should be supported in increasing his/her understanding of how CSA has impacted his/her partner.
The partner is not only influential, but is affected. The article describes this as secondary posttraumatic stress. Among the ways in which the partner's response has potential for damage are denial, downplaying the impact, being insensitive or ignorant, blaming the partner, etc. These highlight the importance of helping the partner respond sensitively.
In therapy, the authors emphasize the importance of addressing any power differences and for clinicians to assess for safety concerns. The literature has been clear that survivors of CSA are more likely to be revictimized in adulthood.
Non-offending family, friends and partners offer the greatest potential for healing, as reported by survivors. In terms of potential for positive healing, many specific suggestions were made for the conducting of couples' therapy. These included exploring the impact the CSA has had, increasing connection by preventing negative affect cycles and trust-building, creating a context of safety, and moderating the process of disclosure about the abuse. The latter can be done by ensuring that the victim has control over the process of recovery and attending to the responses by the partner to encourage supportive rather than invalidating messages.
Time and patience is required in the process and should be normalized. As the dynamics change, for example if the partner become more assertive, the relationship may need to be renegotiated. Ultimately, the primary therapeutic goal is to maintaining the partner's position as a supportive agent toward healing, and the therapy room as a safe environment for the process to unfold.







Sexual Dysfunctions


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Many studies have documented the association between CSA and adult sexual dysfunction, yet results remain inconsistent (Lenoard et al., 2008; Berthelot et al., 2014). This is largely due to differences in operational definition of sexual abuse and sexual dysfunction and lack of standardized measure for sexual dysfunctions (Zwickl & Merriman, 2010). In addition, sample from most of these studies are college students, which is difficult to generalize to the population.






Negative Affect and Perspective on Sexuality

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  • Women with CSA reported more negative sexual affect (fear, anger, and disgust) during sexual arousal and more sexual dissatisfaction than women without CSA. They are also more likely to think their sexual feeling as reduced or inhibited (Bartoi & Kinter, 2008; Schloredt & Heiman, 2003).
  • Negative perspectives about sexuality in general: how she feels about her body and sex organs, how she thinks about sex, how she expresses herself sexually, and how she experiences physical pleasure and intimacy with others (as cited in Zwickl & Merriman, 2010).
  • These negative affect and perspective appears to be significant emotional problems that can interfere with sex or concepts of sexuality (as cited in Zwickl & Merriman, 2010)

Sexual Schemas (Rellini & Meston, 2011)

3 subtypes of sexual self-schema are identified by Cyranowski and Andersen (1994; i.e. The Sexual Self-Schema Scale) as:
  1. Romantic/Passionate (+): romantic, passionate, unromantic, warm, loving, feeling, sympathetic, arousable, stimulating, and revealing.
  2. Open/Direct (+): direct, straightforward, frank, outspoken, broad-minded, experienced, casual, open-minded, and uninhibited
  3. Embarrassed/Conservative (-): cautious, timid, self-conscious, prudent, embarrassed, conservative, and inexperienced.
  • CSA women who have more Embarrassed/Conservative and less Romantic/Passionate sexual self-schemas predicted negative affect prior to exposure to sexual stimuli.
  • More negative sexual self-schemas could lead to negative affect prior to sexual experiences; in turn, reducing sexual satisfaction. (Think sexual script!)

Sexual Function vs. Sexual Distress (Stephenson, Hughan, & Meston, 2012)
  • A study on 176 women in Southwestern USA using the Sexual Satisfaction Scale for Women and the Female Sexual Function Index
  • Women with CSA reported high level of sexual distress despite experiencing high levels of sexual functioning.
  • This population reported more distress regarding sexual activity and experienced clinically relevant levels of distress even if their sexual functioning may be “normal.”
  • Authors concluded that women with CSA have increased risk of being over-diagnosed with sexual dysfunction due to the emotional responses to their traumas instead of sexual functioning.
  • This population experiences unique cognitive and affective processes and filters their sexual experiences through negative self and sexual schemas.
  • Contextual factors: intimacy and trust - additional meaning for CSA women and more have a stronger influences on the level of distress. (Think other-validated intimacy and lower level of differentiation of self.)

Theoretical Model (Zwickl & Merriman, 2010)

Theorized outcomes only, not only possible or absolute outcomes.
Clinical implications:
  • May beneficial for some clients to provide a framework for them to understand their coping process
  • Provide an alternative way of thinking about their abuse that make sense of their current sexual experiences
  • Exploration of new coping strategies other than avoidance and self-destructive methods

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Assessments

  • Trauma Symptom Inventory- 100-item measure designed to assess posttraumatic stress symptomatology.
  • Trauma History Questionnaire - 24-item self-report measure used to examine physical and sexual traumatic experiences
  • Childhood Trauma Questionnaire - 28-item self-report measure that assesses sexual abuse, physical abuse, emotional abuse, emotional neglect, and physical neglect.
  • Golombok Rust Inventory of Sexual Satisfaction - human sexual dysfunction, which consist of Infrequency, Noncommunication, Female Dissatisfaction, Female Avoidance, Female Nonsensuality, Vaginismus, and Anorgasmia
  • The Sexual Satisfaction Scale for Women - 30 items assessing 5 unique domains of satisfaction: contentment, communication, compatibility, personal concern, relational concern
  • Female Sexual Function Index - 19-item measure with items relevant to 6 domains: desire, arousal, lubrication, orgasm, satisfaction, and pain.






Treatments

Treatment for Children and Adolescent Survivors of CSA

  • Sanchez-Meca, Rosa-Alcazar, & Lopez-Soler (2011) conducted a large meta-analysis on treatments of child sexual abuse (CSA) in children and adolescents. This meta-analysis currently appears to be the largest and most empirically valid article in the area of child sexual abuse. Also appears larger than the research that has been done on adult sexual abuse. Other meta analyses have been completed in the area, but they didn’t use as many studies. Using 33 studies (making this the largest meta-analysis at this point in time in child sexual abuse), trauma-focused CBT combined with supportive therapy and a psychodynamic element (such as play therapy) were found to be the most effective treatments. A therapist must keep in mind that this meta-analysis was treating CSA in children and adolescents, and thus might not apply to adults being treated for CSA or adult sexual abuse.
    • Used data from 33 studies. Combined, this led to data from 44 treatment groups and 7 control groups. Not all studies were controlled and randomized, as there were far fewer control groups.
    • Studies used different outcome measures, but the most common were sexualized behaviors, anxiety, depression, self-esteem, and behavior problems.
    • All of the treatment groups showed clinically significant reductions in the various outcome measures (and increases in self esteem). The control groups did not show any clinically significant reductions in problematic symptoms or increases in self esteem.
    • The studies used many different types of treatments, such as trauma focused CBT, supportive therapy, psychodynamic treatments, humanistic treatments, applied client-centered therapy, and Maslow’s self-regulation therapy combined with play therapy.
    • Of these many different treatments, the treatment with the best results combined trauma focused CBT, supportive therapy, and play therapy. Authors theorize this combination allows the therapists to more effectively treat the children and adolescents thoughts, feelings, and behaviors simultaneously.
    • Authors state that it is important to individualize treatment for the children and adolescents, as the impact sexual abuse has can greatly vary from person to person.
    • Since this meta-analysis was conducted on children and adolescents, the same results may not apply for adults. However, it is highly recommended to use this combined treatment approach when working with younger children/adolescents.
    • Longer term therapy treatments had better results than shorter term therapy results.
  • Following up on treating children who have suffered from CSA, a slightly older literature review by Putnam (2002) indicated that CBT for both the child and a non-offending parent was the best treatment. The need to involve a non-offending parent is important because of the support the parent can provide for the child. Additionally, the parent will also need some therapeutic support of their own, as the CSA is often traumatic for the parents as well, especially if the perpetrator was a loved one.
  • A recent study by Misurrell, Springer, & Tyron (2011), which included 48 elementary school aged children who had experienced sexual abuse, indicates children may also benefit from a game-based CBT group program. The game focused on changing internalizing symptoms, externalizing behaviors, sexually inappropriate behaviors, social skills deficits, self-esteem problems, and psychoeducation. The game significantly improved externalizing behaviors and internalizing symptoms and reduced sexually inappropriate behaviors, but did not significantly improve social skills or self-perception. Even so, this study indicates such a group based CBT game could also help treat this population.
  • A critical review of literature by Lev-Wiesel (2008) indicates that while there are many different treatment approaches for survivors of sexual abuse, there is surprisingly little research to support these various approaches. Her critical review did indicate that certain approaches that had been more effective interventions for children who experienced sexual abuse, such as trauma focused CBT or child Centered Therapy, were intended to be applicable for people of all ages who suffer from all types of traumatic events. However, she did not mention if these studies have evidence to support these approaches being used with adults who experienced child sexual abuse or more recent sexual abuse.

Treatment for Adult Survivors of CSA

  • Although there is a fair amount of research out there on treating children who have experienced CSA, less solid research has been conducted on treating adults who have suffered from CSA.
  • Brotto, Basson, & Luria (2008) developed a mindfulness-based groupexternal image 2tHr3NFs5BDL9H-FuQmkkvgxrnabX275pbRVAh7fSfJ4gfiw3ZBO6nBjumI2WtJXjwe4qJPpTMIoeXgEuQMORd1EVM8L7glQpJYx2kfzUp8nIVuEvFCP_12CKoOm9zif5MrBe44 intervention with women who were experiencing sexual arousal disorders. Although the sample size was quite small (26), three 90 minute sessions of group mindfulness training was especially beneficial for the woman in the group who had experienced a history of sexual abuse (eight woman in the group). These findings, despite the small sample size and lack of men or hypersexual survivors, indicate woman with sexual arousal disorders resulting from sexual abuse may experience benefits from a mindfulness-based group intervention. That said, more evidence is required before conclusions are drawn.
  • In our readings, Rellini notes that larger studies with control groups are needed to further test the potential benefits of mindfulness. She also describes that many clinicians working with survivors of sexual abuse have noted that these clients often discussed distraction caused by intrusive thoughts about the abuse, but this may not apply to all of these survivors. As such, it is important during assessment to determine what negative impacts, if any, the history of sexual abuse is currently having in the person’s life.

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  • Research by Edmond and Rubin (2004) indicated 59 female survivors of sexual abuse may benefit from eye movement desensitization and reprocessing (EMDR) which was maintained over an 18 month period of time. However, these results should be interpreted with caution, as previous reviews of EMDR indicate the approach tends to only be effective due to its cognitive processing therapy components, while the eye movements seem to have little benefit (Wilson, Silver, Covi, & Foster, 1996).



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  • According to another review by Leonard & Folette (2002), two approaches have received the most empirical support for treating CSA. The two approaches are Acceptance and Commitment Therapy (ACT), and Emotion Focused Therapy (EFT). ACT combines some behavioral strategies such as exposure and self monitoring, and alsoexternal image PeGLxzNorhtKzjUxUfawiY_yc8adh8mVimLRbJx4i9_F7Y9_6rFlS_QQEEgi07MN6XCcP3iBnRDDr5ljx8mJ7jeUHsJ_UJjgJKpCwKNzoY1ijqCxHovFPPCCloyK6PeVnxQ6zg0 involves acceptance of where a person is currently at, with the end goal of facilitating positive change. EFT is more couples focused than ACT, and is also based strongly on attachment theories. The two main goals of EFT are to access/reprocess affect related to the sexual abuse, and shaping new positive interactions. Leonard & Folette (2002) note that both of these approaches have some empirical studies to support their potential value in treating CSA, but caution the reader that both approaches still warrant further research.


  • external image 7N4LekQRZrqDINLjjUUxnFPP0dLlEcQ7fuJoS0kA3SfBuBzRWLZVUiTrYxu1ANz7I-lPyE9x02m0UOCfbkarJqIkHbcha36_cfOI_1HiWvOrkwaJUsJuCRToyCrfPHkD6GcwjAgA study by MacIntosh & Justin (2008) also indicated that Emotionally Focused Therapy (EFT) could be helpful for a survivor of CSA and their partner. The article also notes that EFT is one of the two empirically validated couples interventions, and has also been known to help couples suffering from other types of psychological difficulties. This study only included 10 couples, all with one partner that suffered from CSA, and did not contain a control group. The couples completed 19 sessions of EFT, and half of the couples showed statistically significant improvements in relationship satisfaction, and statistically significant decreases in trauma symptoms.




















Additional Resources

external image smRW69Quy5jXfcdo4PtK_14ANZge9ZCRWJoMmtZ7bCg8u5z-olQtvI9pBw_s_5OWckIs9s27PkNgY0_LYnJ4tRWa2FL1b2IvfXeTNIJQPPDzmTvVSzB-ZlBtiho44WoPLxnlPOI
Rellini, A. H. (2014). Sexual abuse and sexual function. In G. Corona, E. A. Jannini, M. Maggi, G. Corona, E. A. Jannini, M. Maggi (Eds.) , Emotional, physical and sexual abuse: Impact in children and social minorities (pp. 61-70). Cham, Switzerland: Springer International Publishing. doi:10.1007/978-3-319-06787-2_5





external image wZ-6BDF70pcA05wQb8qZSr6qtgAnGFgJJgDTSAmN4YB67A5hUCc4vPrak2l9kQaai5ENaFpomVuRpII9XavDPVEidlDOzTQEy1ZayEgbkhS0sdImEoNX-tqbz_g6P2slvusU3XIHeiman, J. R., & Heard-Davison, A. R. (2004). Child sexual abuse and adult sexual relationships: Review and perspective. In L. J. Koenig, L. S. Doll, A. O'Leary, W. Pequegnat, L. J. Koenig, L. S. Doll, ... W. Pequegnat (Eds.) , From child sexual abuse to adult sexual risk: Trauma, revictimization, and intervention (pp. 13-47). Washington, DC, US: American Psychological Association. doi:10.1037/10785-002







external image Y_x4iVw40wVpJJYli-8O2VGU7S6C8fFeXF1gpqhMyeiZbapqzoWq-wh97sZ6sWtKPNjq_wuwCEo2rpdW1CxTVjGkhnyYBaIaCYZomh69nqZpwYLls9uvSkTGVPTpjJRlRrtxktEAlexander, P. C. (2003). Understanding the Effects of Child Sexual Abuse History on Current Couple Relationships: An Attachment Perspective. In S. M. Johnson, V. E. Whiffen, S. M. Johnson, V. E. Whiffen (Eds.) , Attachment processes in couple and family therapy (pp. 342-365). New York, NY, US: Guilford Press.




References

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Brotto, L., Basson, R., & Luria, M. (2008). A mindfulness-based group psychoeducational intervention targeting sexual arousal disorder in woman. Journal of Sexual Medicine, 5, 1648-1659.
Child Maltreatment (2012). U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Children’s Bureau.
Cohen, J. A., Deblinger, E., Mannarino, A. P., & Steer, R. A. (2004). A multisite, randomized controlled trial for children with sexual abuse–related PTSD symptoms. Journal of the American Academy of Child & Adolescent Psychiatry, 43(4), 393-402.
Deblinger, E. (n.d.). Questions and Answers about Child Sexual Abuse. The National Child Traumatic Stress Network. Retrieved from http://www.nctsn.org/sites/default/files/assets/pdfs/QAChildSexualAbuseED103007.pdf
Edmond, T., & Rubin, A. (2004). Assessing the long-term effects of EMDR: Results from an 18- month follow-up study with adult female survivors of CSA. Journal of Child Sexual Abuse, 13(1), 69-86.
Gill, M., & Tutty, L. M. (1999). Male survivors of childhood sexual abuse: A qualitative study and issues for clinical consideration. Journal of Child Sexual Abuse, 7(3), 19-33.
Hornor, G. (2010). Child sexual abuse: Consequences and implications. Journal of Pediatric Health Care, 24(6), 358-364.
Kia-Keating, M., Sorsoli, L., & Grossman, F. K. (2010). Relational challenges and recovery processes in male survivors of childhood sexual abuse. Journal of Interpersonal Violence, 25(4), 666-683.
Kilroy, S. J., Egan, J., Maliszewska, A., & Sarma, K. M. (2014). “Systemic Trauma”: The impact on parents whose children have experienced sexual abuse. Journal of child sexual abuse, 23(5), 481-503.
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Leonard, L., & Folette, V. (2002). Sexual functioning in woman reporting a history of child sexual abuse: Review of the empirical literature and clinical implications. Annual Review of Sex Research, 13, 346-388.
Lev-Wiesel, R. (2008). Child sexual abuse: A critical review of intervention and treatment modalities. Children and Youth Services Review, 30, 665-673.
MacIntosh, H., & Justin, S. (2008). Emotionally focused therapy for couples and childhood sexual abuse survivors. Journal of Marital and Family Therapy, 34(3), 298-315.
McElheran, M., Briscoe-Smith, A., Khaylis, A., Westrup, D., Hayward, C., & Gore-Felton, C. (2012). A conceptual model of post-traumatic growth among children and adolescents in the aftermath of sexual abuse. Counselling Psychology Quarterly, 25(1), 73-82.
Miller, R. M., & Sutherland, K. J. (1999). Partners in healing: Systemic therapy With survivors of sexual abuse and their partners. Journal of Family Studies, 5(1), 113-120.
Misurrell, J., Springer, C., & Tyron, W. (2011). Game-based cognitive behavioral therapy (GB-CBT) group program for children who have experienced sexual abuse: A preliminary investigation. Journal of Child Sexual Abuse, 20, 14-36.
Nasim, R., & Nadan, Y. (2013). Couples therapy with childhood sexual abuse survivors (CSA) and their partners: Establishing a context for witnessing. Family process, 52(3), 368-377.
National Intimate Partner and Sexual Violence Survey (November, 2011). Center of Disease Control and Prevention. Retrieved from http://www.cdc.gov/violenceprevention/pdf/nisvs_report2010-a.pdf
Nelson, B. S., & Wampler, K. S. (2003). Further understanding the systemic effects of childhood sexual abuse: A comparison of two groups of clinical couples. Journal of child sexual abuse, 11(3), 85-106.
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