Abstract

This article identifies the impacts of sexual abuse in childhood and adolescence. We conducted an integrative literature review in September 2018 using the Virtual Health Library. A search was conducted using the following descriptors: Sexual Abuse of Children and Adolescents and Sexual Abuse or Child Development. The inclusion criteria were open access full-text original articles published between 2013 and September 2018 in Portuguese, English or Spanish. Sixteen eligible articles were selected after reading the titles and abstracts. The full texts of these articles were read and organized into a table. The studies show that sexual abuse in childhood and adolescence has lifelong psychological, physical, sexual and social impacts. The findings of this study can help alert health care professionals to the importance of investigating the signs and symptoms of sexual abuse given the multiple impacts of abuse on victims’ lives.

Key words
Sexual abuse of children and adolescents; Adult survivors of child abuse; Child development

Introduction

Statistics on the sexual abuse of children and adolescents draw attention to the vulnerability and exposure of this group to this kind of violence. According to Brazil’s National Plan to Combat Sexual Violence against Children and Adolescents, sexual exploration and abuse are elements of sexual violence. Sexual abuse of children and adolescents ranges from lewd acts to sexual penetration by an adult for pleasure, differing from sexual exploration, which involves commercial interests¹1 Brasil. Plano Nacional de Enfrentamento da Violência Sexual contra Crianças e Adolescentes. Brasília: Comitê Nacional de Enfrentamento à Violência Sexual Contra Crianças e Adolescentes, ECPAT Brasil, Conanda, Secretaria dos Direitos Humanos; 2013..

World figures on sexual violence against children and adolescents highlight the worrying nature of the phenomenon. A report compiling data from the period 2016 to 2017 in the United Kingdom showed that there were 54,846 offences against children under 18, indicating an upward trend in cases over time²2 Bentley H, Burrows A, Clarke L, Gillgan A, Glen J, Hafizi M, Letendrie F, Miller P, O'Hagan O, Patel P, Peppiate J, Stanley K, Starr E, Vasco N, Walker J. How safe are our children? The most comprehensive overview of child protection in the UK. [Internet]. Londres; 2018 [cited 2019 Jun 04]. Available from: https://www2.merton.gov.uk/how-safe-are-our-children-2018.pdf
https://www2.merton.gov.uk/how-safe-are-... . In New Zealand, a sexual harm helpline received more than 1,200 phone calls in one month, the majority of which from teenage girls aged 13 to 19³3 Roy EA. New Zealand: majority of callers to new sexual harm helpline are teenage girls [Internet]. The Guardian; 2018. [cited 2018 Jul 5]. Available from: https://www.theguardian.com/world/2018/jun/30/new-zealand-majority-of-callers-to-new-sexual-harm-helpline-are-teenage-girls
https://www.theguardian.com/world/2018/j... .

In Brazil, data from the National Human Rights Ombudsman reveal that, between 2015 and 2016, the Disque 100 hotline received more than 33,000 reports of sexual violence against children and adolescents⁴4 Brasil. Ministério dos Direitos Humanos. Balanço das Denúncias de Violações de Direitos Humanos. [Internet]. Brasilia; 2016. [acessado 2018 Jul 5]. Disponível em: http://www.crianca.mppr.mp.br/arquivos/File/campanhas/disque_100/balanco_disque_ 100__2016__apresentacao_completa.pdf
http://www.crianca.mppr.mp.br/arquivos/F... . A Ministry of Health epidemiological bulletin showed that there were 184,524 reports of cases of sexual violence between 2011 and 2018, 76.5% of which against children and adolescents, which may be related to the greater vulnerability of this age group⁵5 Brasil. Ministério da Saúde (MS). Boletim epidemiológico. Brasilia: MS; 2018..

The situation is aggravated when the perpetrator is a family member, often meaning that the problem is covered up, thus exposing individuals to years of abuse that can have a serious impact on their lives. Data on reports of sexual violence in Brazil between 2015 and 2016 reveal that parents or guardians were the main suspect in 59% of the cases and that 53% of the acts sexual abuse were perpetrated in the victim’s home and 26% in the home of the suspect⁵5 Brasil. Ministério da Saúde (MS). Boletim epidemiológico. Brasilia: MS; 2018.^,66 Brasil. Ministério dos direitos humanos. Balanço das denúncias de violação de direitos humano. Brasília: Ministério dos direitos humanos; 2016.. Another nationwide study based on the medical records of 700 victims of sexual violence in Terezina in the State of Piauí reported that 46.7% of the acts of abuse took place in a domestic setting and that the main perpetrators were parents and stepfathers⁷7 Soares EMR, Silva NLL, Matos MAS, Araújo ETH, Silva LSR, Lago EC. Perfil da violência sexual contra crianças e adolescentes. Rev Interdiscip. [Periódico na Internet]. 2016 [acessado 2018 Dec 9];9(1). Disponível em: https://revistainterdisciplinar.uninovafapi.edu.br/index.php/revinter/article/view/754/pdf_28
https://revistainterdisciplinar.uninovaf... . A study bringing together data from 171 countries also showed that sexual violence is committed by people living with the child or adolescent⁸8 Devries K, Knight L, Petzold M, Merrill KG, Maxwell L, Williams A, Cappa C, Chan KL, Garcia-Moreno C, Hollis N, Kress H, Peterman A, Walsh SD, Kishor S, Guedes A, Bott S, Butron Riveros BC, Watts C, Abrahams N. Who perpetrates violence against children? A systematic analysis of age-specific and sex-specific data. BMJ Paediatr Open. [Serial on the Internet]. 2018 [cited 2019 Jun 04]; 2(1):e000180. Available from: http://bmjpaedsopen.bmj.com/look up/doi/10.1136/bmjpo-2017-000180
http://bmjpaedsopen.bmj.com/look up/doi/... .

One of the main challenges of intrafamilial violence is disclosing the experience. This is because the proximity of the victim to the abuser means that the family often covers up cases of sexual violence in an attempt to protect the perpetrator. In addition, for a number of reasons children and adolescents feel powerless to disclose abuse, including: difficulty understanding the abuse as violence; the victim does not have someone to rely on to make an in(formal) complaint; the victim is discredited by adults or threatened by the abuser⁹9 Nascimento FF, Costandrade PHAC. Políticas públicas como forma de prevenir abuso sexual intrafamiliar contra crianças e adolescentes. Projeção, Direito e Soc. [Periódico na Internet]. 2016 [acessado 2019 Jun 04]; 7(2):1-14. Disponível em: http://revista.faculdadeprojecao.edu.br/index.php/Projecao2/article/view/730/643
http://revista.faculdadeprojecao.edu.br/... ^,1010 Silva PA da, Lunardi VL, Ribeiro JP, Oliveira AMN, Vasquez TCS. Notificação da violência intrafamiliar contra crianças e adolescentes por profissionais de saúde no Brasil. Av en Enfermería. [Periódico na Internet]. 2015 [acessado 2019 Jun 04]; 33(1):142-50. Disponível em: http://www.revistas.unal.edu.co/index.php/avenferm/article/view/40585
http://www.revistas.unal.edu.co/index.ph... .

These factors reinforce the culture of silence¹¹11 Barbosa VMC, Antunes MC, Padilha MGS. A reinserção familiar de crianças e adolescentes vítimas de violência intrafamiliar em acolhimento institucional por medida de proteção: o abuso sexual em foco. Bol - Acad Paul Psicol. 2016; 36(91):286-309., exposing the victim to continued abuse over a prolonged period of time, turning the situation into a chronic problem. Of 311 cases of sexual violence against children and adolescents investigated in Morocco, 67% involved victims who had been abused repeatedly and 78% involved violence committed by the same abuser¹²12 Essabar L, Khalqallah A, Dakhama BSB. Child sexual abuse: report of 311 cases with review of literature. Pan Afr Med J. [Serial on the Internet]. 2015 [cited 2018 May 24]; 20:47. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26090005
http://www.ncbi.nlm.nih.gov/pubmed/26090... . Corroborating the long-term and continuing nature of abuse, a study conducted in Slovenia revealed that children take around seven years to disclose abuse¹³13 Felser ZR, Vidovic L. Maternal Perceptions Of And Responses To Child Sexual Abuse: Materin Pogled In Odziv Na Spolno Zlorabo Otroka. Zdr Varst. [Serial on the Internet]. 2016 [cited 2019 Jun 04]; 55(2):114-20. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27284381
http://www.ncbi.nlm.nih.gov/pubmed/27284... .

Given the long-term and continuing nature of sexual abuse, the early identification of victims becomes even more vital to ensure children receive timely support tailored to their individual needs. In this regard, knowledge of the impacts of this experience in childhood and adolescence on victims’ lives can help professionals who work with children and adolescents identify abuse. The objective of this study was therefore to identify the impacts of sexual abuse in childhood and adolescence.

Methodology

We undertook an integrative literature review. This method seeks to synthesize findings presented by studies on a particular topic or issue, enabling a comprehensive analysis of the literature on the topic of interest and the identification of existing knowledge gaps¹⁴14 Ercole FF, Melo LS, Alcoforado CLGC. Integrative review versus systematic review. Reme Rev Min Enferm. [Serial on the Internet]. 2014 [cited 2018 May 15];18(1):9-12. Available from: http://www.gnresearch.org/doi/10.5935/1415-2762.20140001
http://www.gnresearch.org/doi/10.5935/14... . By broadening the knowledge and understanding of a particular phenomenon, integrative reviews provide important inputs to help shape care interventions and indicate further research.

This study was conducted in accordance with the provisions of Law 9.610/1988 governing copyright, giving proper credit to the authors of the publications used in the review¹⁵15 Brasil. Lei nº 9.610, de 19 de Fevereiro de 1998. Altera, atualiza e consolida a legislação autorais e dá outras providências. Diário Oficial da União. 1998; 19 fev..

To carry out the study, we elaborated a methodological protocol consisting of six stages¹⁶16 Mendes KDS, Silveira RCCP, Galvão CM. Revisão integrativa: método de pesquisa para a incorporação de evidências na saúde e na enfermagem. Texto Context - Enferm. [Periódico na Internet]. 2008 [acessado 2019 Jun 04]; 17(4):758-764. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072008000400018&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... . In the first stage (formulation of the guiding question), we defined the following question using the PICO framework (Chart 1): What are the impacts of sexual abuse in childhood and adolescence on victims’ lives? The PICO acronym stands for: population (P), intervention (I), comparison (C), and outcome (O)¹⁷17 Santos CMC, Pimenta CAM, Nobre MRC. The PICO strategy for the research question construction and evidence search. Rev Lat Am Enfermagem. [Serial on the Internet]. 2007 Jun [cited 2018 May 15];15(3):508-511. Available from: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-11692007000300023&lng=en&tlng=en
http://www.scielo.br/scielo.php?script=s... . It is important to note that we did not use “C”, given that the study did not propose to develop clinical research¹⁸18 Greenhalgh T. Como ler artigos científicos: fundamentos da medicina baseada em evidências. 2a Ed. Porto Alegre: Artmed; 2005..

The second stage (sampling) followed the recommendations of the Statement for Reporting Systematic Reviews and Meta-Analyses of Studies (PRISMA), which consists of a checklist to help researchers develop systematic reviews¹⁹19 Galvão TF, Pansani TSA, Harrad D. Principais itens para relatar Revisões sistemáticas e Meta-análises: A recomendação PRISMA. Epidemiol e Serviços Saúde. [Periódico na Internet]. 2015 [acessado 2019 Jun 04]; 24(2):335-342. Disponível em: http://www.iec.pa.gov.br/template_doi_ess.php?doi=10.5123/S1679-49742015000200017&scielo=S2237-96222015000200335
http://www.iec.pa.gov.br/template_doi_es... . A literature search was performed using the Virtual Health Library (VHL), which brings together the main national and international health databases, thus ensuring a wide variety of results. We used the following combinations of Health Sciences Descriptors (DeCS) in Portuguese, English and Spanish and the Boolean operators “and” and “or”: Sexual Abuse of Children and Adolescents and (Adult Survivors of Sexual Abuse or Child Development). The search was performed simultaneously by two researchers in September 2018.

The following inclusion criteria were used: open access full-text original articles on topics related to the experience of violence in childhood and adolescence written in Portuguese, English or Spanish and published between 2013 and September 2018. Articles in which the impacts were not related to the object of study, duplicate articles and theses, dissertations, books and/or other non-original publications were excluded.

The third stage (data collection) was performed using a descriptive instrument containing the following elements: author, year of publication, periodical, country of study, title, methods and impacts. The fourth stage (critical analysis of the selected studies) was performed after the application of the inclusion criteria and consisted of reading the article titles and abstracts. Publications not related to the object of study and duplicate articles were excluded, resulting in a final sample of 16 eligible articles. The full texts of the 16 articles were read and organized into a Microsoft Excel® worksheet (Figure 1).

The results of the collected material were analyzed using thematic analysis²⁰20 Minayo MCS. Análise qualitativa: teoria, passos e fidedignidade. Cien Saude Colet. [Periódico na Internet]. 2012 [acessado 2019 Jun 04]; 17(3):621-626. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413 -81232012000300007&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... and are presented in Chart 2, which synthesizes the impacts in the following categories: Psychological (low self-esteem, depression, post-traumatic stress disorder – PTSD, sleep difficulties, borderline personality disorder, self-injury, suicidal behavior, psychotic disorders, auditory hallucinations); Physical (tension-type headache, migraine, metabolic syndrome); Sexual (pregnancy, HIV/sexually transmitted infections - STIs, sexual aversion disorder, questioning of sexual orientation, difficulty with orgasm, early onset of sexual activity, risky sexual behavior, selling sex); and Social (smoking, alcohol and other drugs, leaving home (living in the street), shame, revictimization).

The findings, discussion of the results (Stage 5) and presentation of the integrative review (Stage 6) are set out below.

Results

The review included 16 articles addressing the impacts of sexual abuse in childhood and adolescence (Chart 2). Although the VHL includes five databases, studies were only found in two: Lilacs (Latin American & Caribbean Health Sciences Literature) and Medline® (Medical Literature Analysis and Retrieval System Online). All articles included adult participants who had suffered sexual abuse in childhood and/or adolescence.

Discussion

Psychological impacts

The literature on the impacts of childhood sexual abuse show that victims can have the following psychological problems: low self-esteem, depression, post-traumatic stress disorder (PTSD), sleep difficulties, borderline personality disorder, self-injury, suicidal behavior, psychotic disorders, and auditory hallucinations.

With regard to self-esteem, a study undertaken by Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... points out that this problem is a result of intense suffering related to childhood abuse, highlighting feelings of inferiority among women who “feel like a piece of trash”. This suffering, internalized since childhood and/or adolescence, adversely affects the individual’s emotional development. The feeling can get worse over time, ultimately culminating in depression.

Depression was also highlighted as one of the impacts of sexual abuse, being mentioned by four of the studies included in this review. One of the studies estimated that 33% (n = 174) of sexual abuse survivors had depression²²22 Wahab S, Tan SMK, Marimuthu S, Razali R, Muhamad NA. Young female survivors of sexual abuse in Malaysia and depression: What factors are associated with better outcome? Asia-Pacific Psychiatry. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 5:95-102. Available from: http://doi.wiley.com/10.1111/appy.12051
http://doi.wiley.com/10.1111/appy.12051... and two reported a positive association between childhood abuse and the disorder²³23 Bunevicius A, Rubinow DR, Calhoun A, Leserman J, Richardson E, Rozanski K, Girdler SS. The association of migraine with menstrually related mood disorders and childhood sexual abuse. J Womens Health (Larchmt). [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 22(10):871-876. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23930948
http://www.ncbi.nlm.nih.gov/pubmed/23930... ^,2424 Ulibarri MD, Ulloa EC, Salazar M. Associations between Mental Health, Substance Use, and Sexual Abuse Experiences among Latinas. J Child Sex Abus. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 24(1):35-54. Available from: http://www.tandfonline.com/doi/abs/10.1080/10538712.2015.976303
http://www.tandfonline.com/doi/abs/10.10... . It is important to stress just how damaging depression can be, especially at particular life stages, such as pregnancy and the post-partum period²⁵25 Gingnell M, Bannbers E, Moes H, Engman J, Sylvén S, Skalkidou A, Kask K, Wikström J, Sundström-Poromaa I. Emotion Reactivity Is Increased 4-6 Weeks Postpartum in Healthy Women: A Longitudinal fMRI Stud. PLoS One. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 10(6):e0128964. Available from: https://dx.plos.org/10.1371/journal.pone.0128964
https://dx.plos.org/10.1371/journal.pone... . This is because the symptoms can become more pronounced at these times due to increased hormone levels, which can trigger depression²⁶26 Aktas S, Yesilcicek Calik K. Factors Affecting Depression During Pregnancy and the Correlation Between Social Support and Pregnancy Depression. Iran Red Crescent Med J. [Serial on the Internet]. 2015 [cited 2018 Dec 12]; 17(9):e16640. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26473071
http://www.ncbi.nlm.nih.gov/pubmed/26473... . In this regard, one of the studies shows that women are 2.1 times more likely to suffer from depression during pregnacny²⁷27 Barrios YV, Gelaye B, Zhong Q, Nicolaidis C, Rondon MB, Garcia PJ, Sanchez PAM, Sanchez SE, Williams MA. Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence, Poor General Health and Depressive Symptoms among Pregnant Women. PLoS One. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 30;10(1):e0116609. Available from: https://dx.plos.org/10.1371/journal.pone.0116609
https://dx.plos.org/10.1371/journal.pone... .

Like other types of mental illness, depression may be related to trauma caused by sexual abuse, mainly due to the impact of this experience on children’s lives. This trauma can manifest itself in the form of PTSD, as highlighted by Ulibarr et al.²⁴24 Ulibarri MD, Ulloa EC, Salazar M. Associations between Mental Health, Substance Use, and Sexual Abuse Experiences among Latinas. J Child Sex Abus. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 24(1):35-54. Available from: http://www.tandfonline.com/doi/abs/10.1080/10538712.2015.976303
http://www.tandfonline.com/doi/abs/10.10... and Houston et al.²⁸28 Houston E, Sandfort TG, Watson KT, Caton CL. Psychological pathways from childhood sexual and physical abuse to HIV/sexually transmitted infection outcomes among homeless women: The role of posttraumatic stress disorder and borderline personality disorder symptoms. J Health Psychol. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 18(10):1330-1340. Available from: http://journals.sagepub.com/doi/10.1177/1359105312464674
http://journals.sagepub.com/doi/10.1177/... , who revealed a positive association between anxiety disorders and childhood sexual abuse. It is important to highlight that PTSD is characterized by physical and psychological scars and symptoms arising from traumatic situations experienced or witnessed by victims, who repeatedly relive the episode²⁹29 Gabrielson AT, Liu J, Sikka SC. Posttraumatic Stress Disorder and Its Effects on Men's Sexual and Reproductive Health. In: Bioenvironmental Issues Affecting Men's Reproductive and Sexual Health. Amsterdam: Elsevier [Serial on the Internet]; 2018 [cited 2018 Dec 12]. p. 541-556. Available from: https://www.sciencedirect.com/science/article/pii/B9780128012994000359
https://www.sciencedirect.com/science/ar... .

It is important to underscore that everyday situations can trigger the recall of a previous traumatic experience and that the pregnancy and childbirth process can present particularly powerful triggers²⁷27 Barrios YV, Gelaye B, Zhong Q, Nicolaidis C, Rondon MB, Garcia PJ, Sanchez PAM, Sanchez SE, Williams MA. Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence, Poor General Health and Depressive Symptoms among Pregnant Women. PLoS One. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 30;10(1):e0116609. Available from: https://dx.plos.org/10.1371/journal.pone.0116609
https://dx.plos.org/10.1371/journal.pone... . In this regard, Montgomery et al.³⁰30 Montgomery E, Pope C, Rogers J. The re-enactment of childhood sexual abuse in maternity care: a qualitative study. BMC Pregnancy Childbirth. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 15(1):194. Available from: http://bmcpregnancychildbirth.biomedcentral.com/articles/10.1186/s12884-015-0626-9
http://bmcpregnancychildbirth.biomedcent... showed that postpartum women with a history of childhood sexual abuse experienced the “re-enactment of abuse” in situations such as vaginal examination and other intimate procedures, pain during labor and encounters with strangers. This trauma can also trigger insomnia because individuals are in a constant state of alert and may experience nighttime agitation when they manage to rest³¹31 Costa CS. Aplicação de brainspotting em paciente com transtorno de estresse póstraumático e distúrbio de sono. Sleep Sci. [Periódico na Internet]. 2015 [acessado 2019 Jun 04]; 8(4):177. Disponível em: http://linkinghub.elsevier.com/retrieve/pii/S1984006316000213
http://linkinghub.elsevier.com/retrieve/... . Although Swanson et al.³²32 Swanson LM, Hamilton L, Muzik M. The Role of Childhood Trauma and PTSD in Postpartum Sleep Disturbance. J Trauma Stress. [Serial on the Internet]. 2014 [cited 2019 Jun 04]; 27(6):689-94. Available from: http://doi.wiley.com/10.1002/jts.21965
http://doi.wiley.com/10.1002/jts.21965... did not find an association between sexual abuse and sleep difficulties, they did show that when sexual abuse is combined with physical violence and/or neglect it can trigger sleep problems.

Another impact noted by Houston et al.²⁸28 Houston E, Sandfort TG, Watson KT, Caton CL. Psychological pathways from childhood sexual and physical abuse to HIV/sexually transmitted infection outcomes among homeless women: The role of posttraumatic stress disorder and borderline personality disorder symptoms. J Health Psychol. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 18(10):1330-1340. Available from: http://journals.sagepub.com/doi/10.1177/1359105312464674
http://journals.sagepub.com/doi/10.1177/... was borderline personality disorder, which is marked by instability of self-image and interpersonal relationships and psychotic episodes and linked to self-injury and attempted suicide³³33 Finkler DC, Schäfer JL, Wesner AC. Transtorno de personalidade borderline: Estudos brasileiros e considerações sobre a DBT. Rev Bras Ter Comport e Cogn. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 19(3). Disponível em: http://usp.br/rbtcc/index.php/RBTCC/article/view/1068
http://usp.br/rbtcc/index.php/RBTCC/arti... . In this regard, Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... found a relation between depression and suicide ideation, also highlighting that self-injury is one of the impacts of childhood sexual abuse. It is important to stress that self-injury is not necessarily linked to attempted suicide. Self-injury has a punitive connotation and the primary intention is to cause physical pain to suppress or minimize emotional pain³⁴34 Araújo JFB, Chatelard DS, Carvalho IS, Viana TC. O corpo na dor: automutilação, masoquismo e pulsão. Estilos Clínicos. 2016; 21(2):497-515., while with attempted suicide, although the individual decides to take his/her own life, he/she does not want to die, but rather release him/herself from intolerable pain³⁵35 Correia CM, Gomes NP, Couto TM, Rodrigues AD, Erdmann AL, Diniz NMF. Representações sobre o suicídio para mulheres com história de violência doméstica e tentativa do mesmo. Texto Context Enferm. [Periódico na Internet]. 2014 [acessado 2018 Dez 10]; 23(1):118-143. Disponível em: http://www.scielo.br/pdf/tce/v23n1/pt_0104-0707-tce-23-01-00118.pdf
http://www.scielo.br/pdf/tce/v23n1/pt_01... . In this regard, Marshall et al.³⁶36 Marshall BDL, Galea S, Wood E, Kerr T. Longitudinal Associations Between Types of Childhood Trauma and Suicidal Behavior Among Substance Users: A Cohort Study. Am J Public Health. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 103(9):e69-75. Available from: http://ajph.aphapublications.org/doi/10.2105/AJPH.2013.301257
http://ajph.aphapublications.org/doi/10.... noted an association between sexual abuse and suicide ideation.

Attempted suicide is also considered one of the signs of psychotic disorders, which, according to Sheffield et al.³⁷37 Sheffield JM, Williams LE, Blackford JU, Heckers S. Childhood sexual abuse increases risk of auditory hallucinations in psychotic disorders. Compr Psychiatry. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 54(7):1098-1104. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0010440X13001296
https://linkinghub.elsevier.com/retrieve... and Thompson et al.³⁸38 Thompson AD, Nelson B, Yuen HP, Lin A, Amminger GP, McGorry PD, Wood SJ, Yung AR. Sexual Trauma Increases the Risk of Developing Psychosis in an Ultra High-Risk "Prodromal" Population. Schizophr Bull. [Serial on the Internet]. 2014 [cited 2019 Jun 04]; 40(3):697-706. Available from: https://academic.oup.com/schizophreniabulletin/article-lookup/doi/10.1093/schbul/sbt032
https://academic.oup.com/schizophreniabu... , was also associated with childhood sexual abuse. People with psychotic disorders can also experience various types of hallucinations, including auditory hallucinations. Sheffield et al.³⁷37 Sheffield JM, Williams LE, Blackford JU, Heckers S. Childhood sexual abuse increases risk of auditory hallucinations in psychotic disorders. Compr Psychiatry. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 54(7):1098-1104. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0010440X13001296
https://linkinghub.elsevier.com/retrieve... suggest that childhood sexual abuse confers a specific risk for auditory hallucinations. Although seeing and hearing things that do not exist outside the mind, such as imaginary friends, is a normal part of child development, these hallucinations should not continue after childhood. Thus, when auditory hallucinations become an enduring problem they may be sign of sexual abuse³⁹39 Malloy LC, Mugno AP, Rivard JR, Lyon TD, Quas JA. Familial Influences on Recantation in Substantiated Child Sexual Abuse Cases. Child Maltreat. [Serial on the Internet]. 2016 [cited 2019 Jun 04]; 21(3):256-261. Available from: http://journals.sagepub.com/doi/10.1177/1077559516650936
http://journals.sagepub.com/doi/10.1177/... .

Physical impact

With regard to physical impact, it is important to highlight that psychoemotional illness is related to somatization process brought about by the experience of sexual abuse. Somatization is when the body converts mental problems into physical symptoms generally without any defined physiological cause. Somatization was evident in the articles in the form of headaches and metabolic disorders. Tietjen et al.⁴⁰40 Tietjen GE, Buse DC, Fanning KM, Serrano D, Reed ML, Lipton RB. Recalled maltreatment, migraine, and tension-type headache: Results of the AMPP Study. Neurology. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 84(2):132-140. Available from: http://www.neurology.org/cgi/doi/10.1212/WNL.00000 00000001120
http://www.neurology.org/cgi/doi/10.1212... shows that people abused in childhood can experience tension-type headaches, while Bunevicius et al.²³23 Bunevicius A, Rubinow DR, Calhoun A, Leserman J, Richardson E, Rozanski K, Girdler SS. The association of migraine with menstrually related mood disorders and childhood sexual abuse. J Womens Health (Larchmt). [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 22(10):871-876. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23930948
http://www.ncbi.nlm.nih.gov/pubmed/23930... point to a greater chance of developing migraines without or with auras, where the latter is associated with vision or sensory disturbances.

With regard to metabolic syndrome, a study revealed that the prevalence of symptoms was greater in women who experienced sexual violence than in those who did not⁴¹41 Lee C, Tsenkova V, Carr D. Childhood trauma and metabolic syndrome in men and women. Soc Sci Med. [Serial on the Internet]. 2014 [cited 2019 Jun 04]; 105:122-130. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0277953614000422
https://linkinghub.elsevier.com/retrieve... . It is worth noting that metabolic syndrome is linked to compulsive eating, which in turn is associated with changes in habits after trauma, being characterized by the development of various conditions that can increase predisposition to cardiovascular diseases and diabetes⁴²42 Amianto F, Spalatro AV, Rainis M, Andriulli C, Lavagnino L, Abbate-Daga G, Fassino S. Childhood emotional abuse and neglect in obese patients with and without binge eating disorder: Personality and psychopathology correlates in adulthood. Psychiatry Res. [Serial on the Internet]. 2018 [cited 2018 Dec 12]; 269:692-699. Available from: https://www.sciencedirect.com/science/article/pii/S0165178117320371
https://www.sciencedirect.com/science/ar... .

Sexual impacts

Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... point out that one of the sexual impacts of childhood sexual abuse among women is pregnancy. This is aggravated by the fact that essentially unplanned and unwanted teenage pregnancy can lead to psychoemotional problems, particularly when it is the result of sexual abuse often perpetrated by a family member.

In addition to unwanted pregnancy, sexually abused children and adolescents can contract STIs. In this regard, a study undertaken in New York showed that women with a history of childhood sexual abuse were more likely to be diagnosed with HIV or other STIs²⁸28 Houston E, Sandfort TG, Watson KT, Caton CL. Psychological pathways from childhood sexual and physical abuse to HIV/sexually transmitted infection outcomes among homeless women: The role of posttraumatic stress disorder and borderline personality disorder symptoms. J Health Psychol. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 18(10):1330-1340. Available from: http://journals.sagepub.com/doi/10.1177/1359105312464674
http://journals.sagepub.com/doi/10.1177/... . It is important to stress that contracting a STI increases predisposition to other STIs and that a delay in treatment can lead to future problems such as sterility, successive miscarriages, premature birth, neurological problems, and cancer⁴³43 Swartzendruber A, Sales JM, Rose E, Diclemente R. Transitions to Parenthood: Maternal Adjustment Sexually Transmitted Infection Risk Among Young African American Mothers. J Adolesc Health. 2015; 21(3):256-261..

Benoit and Downing⁴⁴44 Benoit E, Downing MJ. Childhood sexual experiences among substance-using non-gay identified Black men who have sex with men and women. Child Abuse Negl. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 37(9):679-690. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0145213413001154
https://linkinghub.elsevier.com/retrieve... draw attention to gender identity conflicts, showing that men abused by other men in childhood and/or adolescence desire and get pleasure from having sex with other men in adulthood. By going against the heteronormative norms imposed by society, this situation can cause intense suffering. On the other hand, Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... suggest that abuse survivors can create an aversion to relations with people from the same sex as the abuser, generating a feeling of ambiguity in relation to their own sexual orientation. In some situations, this aversion extends to sex, due to the disgust felt by victims towards touch and the referencing of past pain and suffering. The authors also suggest that, although victims may be able to have a relationship, they may still experience difficulties with orgasm²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... .

While some victims may have sexual difficulties, others may suffer from hypersexual disorder, leading to compulsive sexual behavior, including unprotected sex with strangers⁴⁵45 Lestrade KN, Talbot NL, Ward EA, Cort NA. High-risk sexual behaviors among depressed Black women with histories of intrafamilial and extrafamilial childhood sexual abuse. Child Abuse Negl. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 37(6):400-403. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23499057
http://www.ncbi.nlm.nih.gov/pubmed/23499... , increasing exposure to STIs. Hypersexuality can be common in childhood, when children begin to get to know their body. When parts of the body that provide pleasure are stimulated, the child may begin to touch him/herself in attempt to repeat the sensation⁴⁶46 Doust ZK, Shariat M, Zabandan N, Tabrizi A, Tehrani F. Diagnostic Value of the Urine Mucus Test in Childhood Masturbation among Children below 12 Years of Age: A Cross-Sectional Study from Iran. Iran J Med Sci. [Serial on the Internet]. 2016 [cited 2019 Jun 04]; 41(4):283-287. Available from: http://www.ncbi.nlm.nih.gov/pubmed/27365549
http://www.ncbi.nlm.nih.gov/pubmed/27365... . Early sexual awakening tends to be damaging for the child’s life, especially since children do not have the emotional maturity to deal with sexuality, as shown by Bellis et al.⁴⁷47 Bellis MA, Hughes K, Leckenby N, Jones L, Baban A, Kachaeva M, Povilaitis R, Pudule I, Qirjako G, Ulukol B, Raleva M, Terzic N. Adverse childhood experiences and associations with health-harming behaviours in young adults: surveys in eight eastern European countries. Bull World Health Organ. [Serial on the Internet]. 2014 [cited 2019 Jun 04]; 92(9):641-655. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25378755
http://www.ncbi.nlm.nih.gov/pubmed/25378... and Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... .

In addition, not all cases of abuse are marked by pain, leading to confused feelings that run from pleasure and affection to fear of the abuser⁴⁸48 Stavas N, Shea J, Keddem S, Wood J, Orji W, Cullen C, Scribano P. Perceptions of caregivers and adolescents of the use of telemedicine for the child sexual abuse examination. Child Abuse Negl. [Serial on the Internet]. 2018 [cited 2019 Jun 04]; 85:47-57. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0145213418303272
https://linkinghub.elsevier.com/retrieve... . Depending on the frequency of abuse, when this mix of sensations last, the victim can end up falling in love with the abuser⁴⁹49 Golan YK. Cinematic love and the Shoah: abnormal love during abnormal times. Post Script, Fall. 2011; 31(1):40.. Another form of abuse is negotiation, when the abuser offers sweets, presents, money or even drugs in exchange for sex or caresses, whereby the victim may begin to understand sex as something that is sellable⁵⁰50 Zeferino MT, Fermo VC, Fialho MB, Bastos FI. Semelhanças e contrastes nos padrões de uso de crack em Santa Catarina, Brasil: capital vs Meio Oeste. Cien Saude Colet. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 22(1):97-106. Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S1413-81232017000100097&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... . In this regard, Lestrade et al.⁴⁵45 Lestrade KN, Talbot NL, Ward EA, Cort NA. High-risk sexual behaviors among depressed Black women with histories of intrafamilial and extrafamilial childhood sexual abuse. Child Abuse Negl. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 37(6):400-403. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23499057
http://www.ncbi.nlm.nih.gov/pubmed/23499... show that 25% of the sample were offered money or drugs in exchange for sex.

Social impacts

Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... , Bellis et al.⁴⁷47 Bellis MA, Hughes K, Leckenby N, Jones L, Baban A, Kachaeva M, Povilaitis R, Pudule I, Qirjako G, Ulukol B, Raleva M, Terzic N. Adverse childhood experiences and associations with health-harming behaviours in young adults: surveys in eight eastern European countries. Bull World Health Organ. [Serial on the Internet]. 2014 [cited 2019 Jun 04]; 92(9):641-655. Available from: http://www.ncbi.nlm.nih.gov/pubmed/25378755
http://www.ncbi.nlm.nih.gov/pubmed/25378... , Benoit and Downing⁴⁴44 Benoit E, Downing MJ. Childhood sexual experiences among substance-using non-gay identified Black men who have sex with men and women. Child Abuse Negl. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 37(9):679-690. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0145213413001154
https://linkinghub.elsevier.com/retrieve... , and Bunevicius et al.²³23 Bunevicius A, Rubinow DR, Calhoun A, Leserman J, Richardson E, Rozanski K, Girdler SS. The association of migraine with menstrually related mood disorders and childhood sexual abuse. J Womens Health (Larchmt). [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 22(10):871-876. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23930948
http://www.ncbi.nlm.nih.gov/pubmed/23930... showed that one of the impacts of sexual violence is drinking, smoking and the use of other drugs. This can be explained as a way of coping with the experience²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... , with victims using these resources to ease suffering, as it is known that some drugs induce a sense of well-being and euphoria and help forget traumatic memories⁵¹51 Clayton HB, Lowry R, August E, Everett Jones S. Nonmedical Use of Prescription Drugs and Sexual Risk Behaviors. Pediatrics. [Serial on the Internet]. 2016 [cited 2019 Jun 04]; 137(1):e20152480. Available from: http://pediatrics.aappublications.org/lookup/doi/10.1542/peds.2015-2480
http://pediatrics.aappublications.org/lo... .

Drug use may also be a result of living on the street due to sexual abuse. Sexually abused children and adolescents often leave home to get away from the situation or may be kicked out because of family conflict, especially in cases where the abuser is a relative. In this regard, Lira et al.²¹21 Lira MOSC, Rodrigues VP, Rodrigues AD, Couto TM, Gomes NP, Diniz NMF. Abuso sexual na infância e suas repercussões na vida adulta. Texto Context - Enferm. [Periódico na Internet]. 2017 [acessado 2019 Jun 04]; 26(3). Disponível em: http://www.scielo.br/scielo.php?script=sci_arttext&pid=S0104-07072017000300320&lng=pt&tlng=pt
http://www.scielo.br/scielo.php?script=s... highlight that sexual abuse affects the individual and weakens the family structure.

The studies highlight the grave social impacts of sexual abuse, hampering the victim’s development and realization of life potential. In this respect, the shame from sexual abuse affects the interpersonal relations of victims, who can become increasingly withdrawn. In a study detailing the experiences of men abused by other men, Benoit and Downing⁴⁴44 Benoit E, Downing MJ. Childhood sexual experiences among substance-using non-gay identified Black men who have sex with men and women. Child Abuse Negl. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 37(9):679-690. Available from: https://linkinghub.elsevier.com/retrieve/pii/S0145213413001154
https://linkinghub.elsevier.com/retrieve... illustrate the feeling of shame when describing the suffering caused by wounded masculinity and the fear of being identified as someone who was abused.

Withdrawn behavior can also make individuals more susceptible to revictimization, through either further sexual abuse or other types of violence. This is because victims use introspection as a defense mechanism, hindering disclosure and thus making other events possible⁵²52 Vilà GD, Littlewood R, Leavey G. Integration of sexual trauma in a religious narrative: transformation, resolution and growth among contemplative nuns. Transcult Psychiatry. [Serial on the Internet]. 2013 [cited 2019 Jun 04]; 50(1):21-46. Available from: http://www.ncbi.nlm.nih.gov/pubmed/23296289
http://www.ncbi.nlm.nih.gov/pubmed/23296... . In this regard, Barrios et al.²⁷27 Barrios YV, Gelaye B, Zhong Q, Nicolaidis C, Rondon MB, Garcia PJ, Sanchez PAM, Sanchez SE, Williams MA. Association of Childhood Physical and Sexual Abuse with Intimate Partner Violence, Poor General Health and Depressive Symptoms among Pregnant Women. PLoS One. [Serial on the Internet]. 2015 [cited 2019 Jun 04]; 30;10(1):e0116609. Available from: https://dx.plos.org/10.1371/journal.pone.0116609
https://dx.plos.org/10.1371/journal.pone... found that women with a history of childhood sexual violence were 3.4 times more likely to suffer further sexual and physical abuse during their lifetime.

Although most of the impacts highlighted by the studies are seen in health services, the majority of health care professionals rarely associate these impacts with sexual abuse. This often means that victims go from service to service and fail to receive adequate treatment, prolonging the experience and resulting in new impacts. Due to the close contact they have with patients, nurses can play a key role in recognizing violence, reducing impacts and shortening the length of time of suffering of children and adolescents or people who were abused in childhood and/or adolescence.

Final considerations

The literature on sexual abuse in childhood and adolescence published between 2013 and 2018 show that this problem has psychological, physical, sexual and social impacts on the victims’ lives.

It is important to highlight that these categories were used for presentation purposes and some impacts permeate others. For example, pregnancy resulting from rape has sexual, psychological and physical impacts. In addition, certain impacts can trigger others, jeopardizing the child’s or adolescent’s development.

Although the articles point to the impacts of sexual abuse, the order in which events took place was not clear and therefore it is not possible to identify causality. However, the findings clearly show that victims of sexual abuse are a particularly vulnerable group.

By identifying existing knowledge on the impacts of sexual abuse, the findings of this study can help alert health care professionals to the importance of investigating sexual abuse as a potential cause of the signs and symptoms mentioned by patients. Nurses play a key role within primary health care settings due to the close contact they have with patients and their families, which is fundamental to the process of establishing bonds, investigation and care. In this regard, the care provided to victims should not be limited to clinical treatment, but rather take into consideration the patient’s history of violence in order to minimize its impact.

None of the articles highlighted impacts during childhood, which may be because the studies were conducted with adults, who may not have linked some of the impacts to the experience of sexual abuse. It is also worth highlighting that memory bias may occur when participants are asked to recall evens from the distant past. Further research on sexual abuse in childhood and adolescence should therefore be conducted with children and adolescents.

References

Publication Dates

History