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Sexual Abuse in Women

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CLINICAL RESEARCH

Sexual Abuse and Subsequent Suicidal Behaviour: Exacerbating Factors and Implications for Recovery Cate Curtis

ABSTRACT. Suicidal behaviour is a cause for concern among many western countries; in general, it is most common among young women. This research used qualitative methods to explore the narratives of 24 Cate Curtis, PhD, lectures in psychology at the University of Waikato, New Zealand. She is interested in female self-harming behaviour, including self-mutilation and suicidal behaviour; social factors implicated both in engaging in self-harm and in recovery, particularly the roles played by family and friends; and barriers to help-seeking behaviour such as stigma. She is also interested in the ways people diagnosable with mental illness make sense of their experiences of being “unwell” and their experiences as consumers of mental health services. Cate has also worked in a number of social service agencies as a youth and community worker. Address correspondence to: Cate Curtis, PhD, Psychology Department, University of Waikato, Private Bag 3105, Hamilton, New Zealand (Email: ccurtis@waikatoc.nz). The author wishes to thank the participants who candidly shared their experiences of suicidal behaviour and sexual abuse, and hopes that the opportunity to have their voices heard through this paper goes some way to repay their contribution. This research was supported by funding from the Foundation for Research, Science & Technology and the University of Waikato. Submitted for publication 11/10/04; revised 03/18/05; accepted 03/20/05. Journal of Child Sexual Abuse, Vol. 15(2) 2006 Available online at http://www.haworthpress.com/web/JCSA  2006 by The Haworth Press, Inc. All rights reserved. doi:10.1300/J070v15n02_01

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women, to contextualise their insights, and to examine the meanings of events leading to and implicated in the recovery from suicidal behaviour. The research confirms sexual abuse as a common precursor to suicidal behaviour; several women asserted that they would not have attempted suicide if they did not have a sexual abuse history. The women noted that the effects of sexual abuse were exacerbated by problems with disclosure, linking to issues of control, with implications for intervention and recovery. [Article copies available for a fee from The Haworth Document Delivery Service: 1-800-HAWORTH. E-mail address: Website: © 2006 by The Haworth Press, Inc. All rights reserved.]

KEYWORDS. Sexual abuse, suicidal behaviour, adolescent mental health, intervention

Barriers to early death are increasingly strengthened through advances in medical science; we are more aware of the causes of premature death than ever before. Yet some young people continue to attempt (and in some cases succeed) to take their own lives. Internationally, adolescents and young adults are at greater risk of suicidal behaviour than other age groups (Gould et al., 1998; Romans, Martin, Anderson, Herbison, & Mullen, 1995), and while males complete suicide at higher rates than females, rates of suicidal behaviour in general are considerably higher for females (Ministry of Youth Affairs, Ministry of Health, & Te Puni Kokiri, 1998). Examinations of risk factors for suicidal behaviour have largely been quantitative in nature, seeking to determine correlations. Also, the majority of studies have been conducted with clinical populations. The research discussed in this paper attempts to address these possible methodological issues through the use of qualitative methods with a community sample. The paper discusses the experiences of women who engaged in suicidal behaviour while under the age of 25 through their first-hand accounts. Of particular interest is the relationship between sexual abuse and subsequent suicidal behaviour, and how sexual abuse impacts upon help-seeking behaviour and the efficacy of interventions for suicidal behaviour. Adults who have been victims of sexual abuse as children or adolescents report significantly greater symptoms indicative of depression, anxiety, and self-abusive and suicidal behaviour. In a 1992 study by Saunders, Villeponteaux, Lipovsky, Kilpatrick, and Veronen, abuse survivors were significantly more likely than others to meet diagnostic

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criteria for agoraphobia, panic disorder, obsessive-compulsive disorder, major depression, social phobia, and post-traumatic stress disorder (PTSD). Vajda and Steinbeck (2000) found that childhood sexual abuse is a stronger predictor of repeated suicidal behaviour than individual characteristics and other stressors, and Read, Agar, Barker-Collo, and Davies (2001) found that “Current suicidality was predicted better by child sexual abuse (experienced on average 20 years previously) than a current diagnosis of depression” (p. 367). Rodriguez-Srednicki (2001) reported increased rates of drug use, alcohol abuse, disordered eating, risky sex, dissociation, self-mutilation, and suicidality in a sample of 175 female college students who were survivors of childhood sexual abuse, as compared to 266 female college students with no reported history of abuse. Likewise, elevated rates of depression, anxiety, low self-esteem, drug or alcohol abuse, suicide attempts, and psychiatric admission were found in McCauley and colleagues’ (1997) study of childhood physical and sexual abuse in American women. Similar findings are reported by Polusny and Follette (1995), Silverman, Reinherz, and Giacona (1996), Stepakoff (1998), Read et al. (2001), and Read, Agar, Argyle, and Aderhold (2003) have linked sexual abuse to hallucinations, delusions, and thought disorders. Sexual abuse has been linked to a number of negative psychological outcomes in addition to diagnosable disorders. Effects include trouble sleeping, nervousness, thoughts of hurting oneself, and learning difficulties. Women whose abusive experiences occurred within the family are at greater risk of disturbance than other women (Sedney & Brooks, 1984). Wagner and Linehan (1994) reported that not only are women who have been sexually abused more likely to engage in deliberate self-injury, their behaviour is also more likely to be lethal than that of women who did not report abuse. More recently, Gladstone, Parker, Mitchell, and Malhi (2004) argued that depressed women with a history of childhood sexual abuse may require specifically tailored interventions. While a casual reading of the literature may suggest that most women who have been sexually abused go on to experience psychological problems, the Otago Women’s Health Study found that only one in five women who reported sexual abuse as a child developed a psychiatric disorder (Ministry of Health, 1998). Reviewing a number of studies, Goodyear-Smith (1993) argued that the other forms of abuse and family dysfunction that tend to occur alongside sexual abuse may in fact play at least as great a part in later depression and psychological problems. Boudewyn and Liem (1995) suggested that the longer the duration and the more frequent and severe the sexual abuse, the more depression and self-destructiveness is likely.

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In a large random community study, Romans, Martin, and Mullen (1997) found that of their 252 participants, 26% of the participants reported sexual abuse before age 12 and 32% were sexually abused by the age of 16. Twenty-three (4.8%) of those interviewed reported a history of deliberate self-harm, and 22 of these 23 reported childhood sexual abuse. The one woman who self-harmed without a history of childhood sexual abuse reported sexual and physical assault as an adult. It should be noted that the vast majority of women who were sexually abused did not report self-harm. A clear “dose effect” was found: the more frequent and intrusive the childhood sexual abuse, the stronger the association with selfharm. This was also found in a study by Mullen, Martin, and Anderson (1996). Sexually abused participants who had self-harmed were more likely than other survivors of sexual abuse to report depression, anxiety disorders, eating disorders, and to drink alcohol in excess of the recommended guidelines. They were also more likely to have experienced psychosocial disadvantage in their families of origin, such as low care/ high control relationships with their parents, parental discord, paternal depression or alcohol abuse, and physical abuse. Romans and colleagues’ study clearly demonstrates that although not all women who have been sexually abused go on to harm themselves, the majority of women who harm themselves have been sexually abused. Although exact figures cannot be obtained and various definitions1 are used in the research, sexual abuse in girls and young women is not uncommon, and it is generally accepted that females are far more likely to be victims of sexual abuse than males. For example, Saunders and colleagues (1992) reported that 10% of the women in their study in South Carolina had been raped during childhood, a further 15.6% had been molested, and another 12% had been the victims of non-contact sexual assault (such as indecent exposure). When studied at age 18, 17% of females in a longitudinal study reported experiencing sexual abuse before age 16 (Fergusson, Lynskey, & Horwood, 1996). However, it has been suggested that survivors in this age group are inclined not to report the abuse they have suffered (Ministry of Health, 1998). A study of 3000 women aged 18-65 (Anderson, Martin, & Mullen, 1993) reported 32% being sexually abused before age 16. Using a somewhat narrower definition2 of sexual abuse than some, Muir (1993) found prevalence rates of 38% among women and 10% among men in her sample of university students. However, Romans, Martin, Anderson, Herbison, and Mullen (1995) argued that until recently most studies have involved atypical samples such as social agency clients and clinical inpatients, and criticisms of the link between childhood sexual abuse and later suicidality

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have been based on these methodological issues; for example, clinical inpatients may not be representative of the wider population of survivors of sexual abuse. Disclosure of abuse appears to be difficult for many survivors of sexual abuse, particularly disclosure to police or others outside their circle of significant others. This may have implications for the efficacy of counselling and therapy. International studies reviewed by Muir (2001) suggested that 20-30% of survivors of childhood sexual abuse do not disclose until adulthood, and in over half the cases where disclosure occurred during childhood (usually to a parent or parent figure or friend; only 4% disclosed to a community figure, such as police, teachers, or social workers), no action was taken. The majority of participants in Muir’s (1993) study reported feeling scared, humiliated, guilty, and powerless at the time of the abuse. When asked how they felt immediately after disclosure, approximately one-third gave negative responses, such as guilt or shame. In some cases, the response of the person to whom they had disclosed was negative or unsupportive. For some participants, negative responses to the question seem largely predicated on a lack of response by the person disclosed to, or little change to the situation. Another study conducted by Muir (2001) found that fear of the consequences frequently affected women’s ability to disclose. Anderson and colleagues (1993) reported that only 7% of sexually abused participants reported the abuse to police or social services, and Romans, Martin, and Mullen (1996) suggested that sexual abuse by a family member is much less likely to be reported to police or social services than if the abuser is outside the family. In many cases, fears were not unfounded: disclosures were often met with disbelief or rejection on the part of the confidant. Similarly, Myer (1985) reported that of 43 mothers who attended a programme for mothers of father-daughter incest victims, only 56% protected their daughters, with 9% taking no action and the remaining 35% rejecting their daughters in favour of their partners (the perpetrators of abuse). Members of the latter two groups either denied the abuse took place, or blamed their daughters, claiming, for instance, that their daughters were seductive, provocative, or pathological liars. Denial of abuse during childhood is often particularly disempowering and engenders a sense of betrayal and may result in the abuse continuing. Withholding disclosure may be a way to retain control over one’s memories and emotions; as Muir (2001) discussed, control (or the lack of it) is frequently an important issue for survivors of abuse. Control may also be maintained through selective disclosure, or choosing confidants that maximise confidence about disclosure. It seems possible that

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disclosure may impact mental health and potential suicidality, depending on how the disclosure is dealt with. If abuse is disclosed when it first occurs and is appropriately dealt with, the abuse survivor will have the opportunity to take whatever steps she feels necessary to re-establish her emotional equilibrium. On the other hand, if she is unable to disclose the abuse, or it is not dealt with appropriately, she may be at greater risk of feelings of guilt, anxiety, low self-esteem, and depression and the abuse may continue. These emotional responses could, in turn, lead to suicidality. Holguin and Hansen (2003) suggested that in addition to the impact of the abuse itself, the consequences of being labelled as sexually abused may have detrimental effects. They argued that the combination of negative expectations and biases may create a self-fulfilling prophecy, but acknowledge that further research into this area is required. Additionally, the mother’s response to a disclosure of sexual abuse is central to her daughter’s recovery (Candib, 1999). Furthermore, perpetrators of sexual abuse are rarely identified and even more rarely punished (Candib, 1999); if a girl’s mother does not support her, she may well receive no support at all. A link between delayed disclosure of abuse or inadequate response to disclosure and subsequent suicidal behaviour does not appear to have been researched. However, given what is known about increased likelihood of suicidal behaviour among survivors of sexual abuse, it seems plausible that the addition of a lack of support to deal with the abuse may exacerbate suicidality. In summary, the literature reviewed suggested that sexual abuse leads to an increased likelihood of depression, anxiety, trauma, and substance abuse, all of which have been associated with suicidal behaviour. While it would be incorrect to say that the majority of survivors of sexual abuse engage in suicidal behaviour, there is no doubt that the risk is increased, and Romans and colleagues’ findings (Romans et al., 1995, 1997) suggested that the majority of young women who attempt suicide have been sexually abused. Candib’s (1999) and Muir’s (2001) findings that those who do not disclose abuse or whose disclosure does not result in appropriate responses are at increased risk of distress suggests that the likelihood of subsequent suicidal behaviour may be raised in these groups; however, there appears to be little research on this topic. This research sought to explore the perceptions of women who had engaged in suicidal behaviour. While the literature discussed above clearly points to a link between childhood sexual abuse and subsequent suicidal behaviour, the author was concerned to avoid assumptions about linkages between the two. The purpose of the research was to determine

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how the women concerned (i.e., the survivors of suicidal behaviour) saw their behaviour, what they considered to be the factors that led to their suicidality, how they made sense of their actions, and how they moved beyond suicidal behaviour. Therefore few restrictions were placed on criteria for inclusion in the study and a research method was chosen that minimises the impact of the preconceived ideas of the researcher. Experience of sexual abuse was not a necessary criterion for inclusion in the study. Rather, this was a study of female suicidal behaviour that revealed a high prevalence of sexual abuse in participants’ histories. METHODS The population of interest in this research was women who engaged in non-fatal suicidal behaviour while under age 25. As noted by Gould and colleagues (1998), clinical samples demonstrate higher rates of co-morbidity than community samples, leading to an increased risk of sample bias. Due to this potential bias, and because a large number of young female self-injurers do not come to the attention of a mental health professional, a qualitative approach that included a non-clinical population was used. Eligibility for participation in the research included prior engagement in suicidal behaviour, while under age 25, cessation of suicidal behaviour for at least one year, and self-assessed as having recovered from suicidality. The latter two criterion were included both to ensure a degree of safety from distress that might have occured through taking part in the research and to increase the likelihood of participants having had some time to reflect on the cessation of their suicidal behaviour. However, it is acknowledged that the decision that suicidal behaviour should have ceased at least one year prior to participation is somewhat arbitrary. Personal experience of sexual abuse was not a criterion for participation. Participants were recruited through presentations made to third-year and graduate psychology classes, through items placed in magazines and newspapers, via the e-mail lists of relevant information networks, and through letters and information sheets sent to relevant community organisations such as women’s groups and community support groups. Potential participants were invited to contact the researcher. An initial recruitment discussion took place during which the purpose of the study was discussed, along with eligibility criteria. Participants were asked if they had questions and then offered a written information sheet. Following this, eligible participants were invited to take some time to consider whether they wished to proceed and to contact the researcher again

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if they did. Most participants decided immediately that they wished to proceed and made an appointment for an interview. Two possible participants were not heard from subsequent to the recruitment discussion, and one cancelled her appointment. Participants A total of 24 women took part in the research. The participants formed a diverse group; efforts were made to recruit participants from a variety of backgrounds, in an attempt to obtain a sample as representative of the population of interest as possible, given the sample size. The youngest participant was aged 21 at the time of the interview, while the oldest was 46. The average age was 29.6 years. All participants were born in New Zealand and of European descent, although two also were of Maori ethnicity (the indigenous people of New Zealand) and one was part-Asian. Most (n = 23) of the participants spent their childhood living with at least one biological parent, with the remaining participant had been adopted. However, only 11 participants reported that their biological parents were cohabiting at the time of the participant’s first suicide attempt. In eight cases, the parents separated at some point of the participant’s childhood or adolescence; in three cases one parent had died, and in one case both parents had died. Eleven participants were living in cities at the time of their first suicide attempt, nine in towns, and four in rural areas. Socio-economic status and education levels were mixed, possibly as a result of the recruitment process; thirteen participants had completed some university courses. Interview and Procedures An open-ended, semi-structured method of interviewing was chosen in recognition that an attempt to fit the participants’ varied experiences into a “one size suits all” structure would risk losing the subtleties of their interpretations. This method facilitates access to information the researcher could not have considered (Burns, 1994). In line with the narrative approach, once the preliminaries to the interview had been conducted (discussion about consent, recording of the interview, making the participant comfortable, discussion of the topic, etc.), the participants were encouraged to tell their “story,” beginning with the background to becoming suicidal. Participants were asked in general terms how or why they became suicidal. They were not prompted by having possible risk factors suggested, such as sexual abuse. During this stage, the researcher’s

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role was solely one of encouraging the process of story-telling. The second stage was one of seeking clarification and elaboration as required. Interviews lasted an average of two hours and all except three were conducted face to face, with two others being conducted by telephone and the remaining one a combination of telephone and electronic mail. Face-to-face interviews were conducted at the place of choice of the participant (in one case, at the participant’s workplace; in another, at the offices of a participant’s counsellor; and the remainder evenly split between the researcher’s university office and the participants’ homes). All face-to-face and telephone interviews were audio-taped. When transcribing was complete (within two weeks), a copy of the transcription was given to each participant to check for accuracy. No participants requested changes be made other than adding or correcting some details. Thematic data analysis was performed utilising the QSR Nud*ist qualitative data analysis software package. A suitable coding structure was developed through this process, with branches for risk factors, other self-harming behaviours, interventions/therapies, and factors in cessation. Results A range of both proximal and distal factors were discussed by participants as contributing to their suicidal behaviour. Although suicidal behaviour was often triggered by an immediately preceding event, it was clear from the participants’ narratives that suicidal behaviour occurred against a background of long-term disturbance and dysfunction. All participants spoke about combinations of factors, and, with the exclusion of two women who considered that their suicidal behaviour was primarily due to biological causes (Kate and Lucy3), all the participants spoke of issues within their family being key contributors. While the divorce of parents does not seem particularly common (eight out of 24 participants), most of the others spoke of a large amount of parental conflict that did not result in divorce. Additionally, there were five parental deaths, two of which were suicides, and a number of other issues as discussed above. Almost all participants spoke of some level of physical or emotional abuse within the family that was sufficiently severe to be considered a cause of their suicidal behaviour. These family issues are identified in Table 1. Sexual abuse (as defined by the individual participant) was more commonly reported than would be expected from statistics, which suggests prevalence rates between 17% and 38%; in the present sample, 16

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Stressor Experienced Sexual abuse (11 perpetrated by family members, an additional 5 reported sexual abuse outside the family) Physical and/or verbal abuse Family suicidal history (threat, attempt, or complete) Parental divorce/separation Parental conflict, but not separation Parental death Parental substance abuse (most commonly alcohol) Religious beliefs Financial difficulties Death of siblings Other dysfunction, e.g., violence from father directed at mother Parental schizophrenia

Participant n = 24 16 15 9 8 5 5 4 4 3 2 2 1

of the 24 participants had been sexually abused, 11 by family members. It is also possible that not all participants disclosed abuse in the course of the research; indeed, one woman did not disclose during the interview, but contacted the author afterwards to discuss this. In addition, two of the remaining participants identified the loss of their virginity as being a key precipitator to a suicide attempt. In both these cases, the young women had religious backgrounds and alcohol had been consumed. Although neither considered that rape had occurred, it seems that a degree of coercion was involved. For example, Louise stated “I lost my virginity during the [ninth grade] summer break. I didn’t want to, but I was drunk.” Of the sixteen who had been sexually abused, in most cases a family member was a perpetrator (in two cases, there was more than one abuser). In three cases, the perpetrator was their father or step-father, in three cases it was a brother, and in two cases it was their maternal grandfather; three women chose not to specify the exact nature of the family relationship. Of the five cases in which the abuser, or one of the abusers, was not a family member, in three cases there were other links with the family: in one case the participant’s brother’s friends were abusers, and in two cases the mother’s boyfriend was the perpetrator. Three participants did not specify their relationship to the abuser.

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All the women who reported a history of sexual abuse identified the abuse as a significant factor in becoming suicidal. Lara simply stated, “I had a total lack of self-worth.” Wendy stated, The abuse [by Wendy’s older brother] had a big effect on how I saw friendships, and this was made worse because my brother involved his friends and another girl I went to school with. I saw the abuse as normal playing for several years, and a few times I tried to initiate it with other friends, when I was about seven. I was rejected by these friends . . . I felt hurt and confused. My brother took advantage of that, saying that no one liked me and I’d never have any friends. So I became very shy, and also reluctant to say no to “playing” with him and his friends. Another woman, Heidi, stated, “I hated men, I had violent fantasies and was uncomfortable with being touched. The abuse made me feel bad and evil . . . . My Christian upbringing taught me that character was linked to chastity, and I had lost my chastity.” Jackie continues to have great difficulty talking about the sexual abuse she suffered; she was only able to refer to the topic by saying: Stuff happened that I can’t really talk about . . . . I always tried not to think about it, so when I started cutting [self-mutilating] and attempting suicide I didn’t think about it being because of “it.” . . . I just blocked it out . . . It’s not like I forgot about it though. Looking back it was a big part of why. I hated myself, but I didn’t make a conscious connection. Jackie was able to indicate that “it” was sexual abuse, but did not discuss details of the abuse. For many participants, the impact of sexual abuse was exacerbated by issues around receiving help or disclosure. Wendy stated, I’m sure my mother knew or at least suspected–she did make some efforts to prevent my brother and me being alone–but she didn’t do anything that actually stopped it [the abuse]. She didn’t tell Dad, she didn’t try to get any outside help, she didn’t even talk to me about it. I know she probably didn’t know how to deal with it. She probably was trying to pretend it wasn’t happening, but at the end of the day I was helpless. She knew and she didn’t help me. It went on for years, and I’ll never forgive her.

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Some of the women did not disclose the abuse for some years, and one never had disclosed it prior to taking part in the research. For some, simply having no one to confide in was a source of distress. Of those who did disclose, three were not believed. Naomi, for example, stated that I told my mother about the abuse but she didn’t believe me . . . . I was also physically abused by my step-father, and Mom always took his side. It was a mutual decision for me to go to boarding school then, although it felt like I had no choice. Some years later Naomi’s mother told her that she did believe her, but when Naomi told her more of the details her mother told other family members that Naomi was “making up stories.” After her mother killed herself and Trisha’s sister, Trisha’s father had begun sexually abusing her. She describes that What had happened was too terrible for me to put into words [while it was happening] . . . [Eventually] I saw the family doctor, but he questioned the accuracy of what I was saying, which was devastating. It took my last drop of courage to tell him, and then I wasn’t believed. Jen, whose parents were dead and who lived in a boarding school as an adolescent, stated, During the school vacations I went to stay with my older sister, who was married. I was molested by my sister’s father-in-law during these vacations. When I told my sister she didn’t believe me, so I still had to go back every holidays. Three participants no longer have a relationship with their mother because they were not believed when they disclosed abuse by their stepfather or mother’s boyfriend. Two participants, Jackie and Lara, spoke about disclosing abuse to mental health workers and being told that the abuse “didn’t count,” or that it was “just kids playing.” In Jackie’s case, this was the first time she had disclosed the abuse. Both found having their experiences minimised in this way to be disempowering: “It counted to me, it had been one of the main causes of me feeling like I did and hating myself.” Jackie has not been able to talk about the abuse since, although she feels pressured to do so by her current therapist.

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In two cases that involved the maternal grandfather, the participants’ mothers had also been abused by the same man but had not previously disclosed it. In these two cases, the abuse of mother and daughter, when disclosed, led to additional disruption through feelings of guilt, anger, and shame on the part of the participant’s mother. My mother had a breakdown as a result–she had blocked out her own experience of abuse. After she [Heidi’s mother] came out of hospital I more or less began parenting her. Mom felt she had to stop seeing her family, who had been a huge source of support for us. We were virtually disowned, although I’d been my grandparents’ “princess.” My grandfather refused to get help. (Heidi) Heidi and her mother sought help from their church and were told to “forgive and forget.” They did not find this approach helpful. Of the sixteen who had been sexually abused, four instigated court proceedings. Of these, only one (Sue) can really be described as having a positive outcome: “I got a sense of control when I went to court. He had taken my power away, but now he’s in jail and I’ve got some power back.” Of the other three, one found the process devastating, and it led directly to suicidal behaviour. Heidi stated, The decision to take him to court was a disaster. I had to give an evidential interview and that was the end really. I hated myself, I wanted to die, I was so depressed. The interview was fucking horrible. . . . Character and chastity are tied together and I felt evil. Another woman, Yvonne, took one of her abusers to court but he was not convicted. This was a “slap in the face” for Yvonne, as she felt her experience was invalidated. Although Richelle’s father was found guilty of rape and is serving a prison sentence, he remains adamant that he is innocent, which, for Richelle, to some degree negates the effect of his being convicted. Several participants said that emotional abuse and manipulation was as traumatising as sexual abuse. Jane stated that “Words don’t leave you, they define you.” Many of these participants spoke passionately of the distress this abuse caused them. In addition to being a source of depression and/or anxiety, the emotional abuse contributed to poor selfesteem and feelings of powerlessness and hopelessness. Many participants spoke explicitly of feeling powerless or out of control of some aspect of their lives, often as a direct result of abuse.

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This loss of control was usually cited by participants either in the body (abuse) or emotions (e.g., feeling that depression was out of control). In some cases, it was of a more practical nature; Jen spoke of her boarding school experiences, Maree of being on a social security benefit. Parental deaths also seem unusually common, considering the age group. These deaths usually had both emotional and practical consequences. A range of more immediate factors compounded the background issues and were the triggers for suicide attempts. Loss of self-identity was mentioned by a number of participants, in several cases because of issues at school, but three participants spoke of a sporting injury being the cause; being a successful sportswoman was important to their self-identity, and when injury meant they had to give up their sport they felt, as Evelyn puts it, “like I didn’t know who I was anymore.” Relationship break-up was mentioned by a number of participants as a trigger. Other factors discussed but which appear to concern relatively few participants are sexuality, academic failure per se, and the influence of friends. The overall impression is that without the distal factors the suicide attempt(s) would not have occurred; the triggers were not sufficient cause in themselves. In addition to discussing precursors and contributing factors, participants spoke about their experiences in recovering from suicidal behaviour. Fifteen participants had contact with a health service-based counsellor or other therapist (as opposed to a community-based service). Seven participants had contact with more than one psychiatrist, psychologist, or other therapist; all participants felt that at least one of the professionals they saw in this context was unhelpful, and eight described it in terms that suggested that counselling or therapy had detrimental affects. Jen discussed psychiatric treatment as a trigger to her suicide attempt: He badgered me for details of my sex life. I knew this approach was completely wrong, but I felt absolutely powerless. The day before a session with this psychiatrist I collected up all the pills I could find and took them. Jen had been feeling powerless for a number of reasons. She was living in a boarding school, following her parents’ deaths. During her holidays, the only place she could go was to her married sister’s home, where she was sexually abused. The approach of this psychiatrist was “the final straw.” Lara’s experience seems typical:

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The first counsellor I saw was a psychologist who made me tell him everything about the abuse although I didn’t feel ready too. I was told to behave like an adult, and use the right words . . . . His judgement of the abuse was that it was “just kids playing.” After seeing him, I was so upset I vomited. The second counsellor I saw I persevered with for a year, but no progress was made–she didn’t really get to the crux of anything. The third counsellor was a lesbian; I thought I would be able to relate to her. But she minimized my experiences, saying that “others have been through much worse.” Counsellors always made me feel that they were the professionals and knew best whereas I was silly, weak, and “born feeling blue.” Lara’s experiences around disclosure of sexual abuse were echoed by Jackie, who described being pressured to disclose, “because if you cut yourself or have BPD everyone assumes you must have been sexually abused,” and subsequently being told that her abuse “didn’t count.” Jackie found disclosure very difficult, and to have her experience minimised was very disempowering. She continues to feel pressured to discuss her experiences of abuse in her current therapy, but is not able to do so. While in some cases it appears that participants were not particularly proactive in seeking additional help, it should be remembered that many participants reported loss of self-esteem, shyness, and feelings of helplessness that may combine with the loss of self-motivation characteristic of depression to render the individual incapable of extended efforts to seek assistance. Wendy stated, I asked the doctor [at an alcohol and drug assessment centre] to admit me to a residential facility, but he said I didn’t seem to need it. . . . I wanted to be in a residential facility because I was struggling to cope with my emotions, but I wasn’t able to explain that. He would of asked why I felt like that, and I couldn’t answer without talking about the abuse. So I couldn’t say anything. Although Trisha did speak to her family doctor about the sexual and physical abuse she was suffering at the hands of her father, “He questioned the accuracy of what I was saying, which was quite devastating. It took every last drop of courage to tell him, and then he didn’t believe me.” Counselling with community-based organisations seems to have been more effective than with therapists working in the medical system,

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although the participants’ perceptions were still mixed. Thirteen participants had sessions with at least one counsellor; organisations ranged from specialist sexual abuse services to Christian counselling services. Only two participants reported that the first counsellor they saw was helpful. Six participants persevered and consulted other counsellors. Of the eleven participants who were dissatisfied with the first counsellor they consulted, the majority simply found the experience to be ineffective. Three found the experience to be actually detrimental. Wendy stated, It [engaging in therapy] was over a period of about 15 years. . . . It took a long time to get to a place where I was able to get past the shame and talk about the important stuff, and an equally long time to find someone trustworthy, who I didn’t feel was judging me, who would believe me. In other cases, the participants’ simply did not feel ready to talk, particularly where disclosure of sexual abuse was part of the problem. Tracey stated, “The doctor referred me for counselling, but I only went 2 or 3 times because I didn’t feel ready, and I didn’t want anyone to know what had happened to me.” Wendy adds, The counsellor I was seeing was easy to get on with and understanding, and seemed to be interested in underlying problems, but I never got close to telling him about what had happened–I wouldn’t have even admitted it to myself at that point. Conversely, Trisha describes why a specialist sexual abuse service was helpful: I was validated and told the choices I had made were good choices, as they had enabled me to survive. They provided unconditional acceptance, and affirm your courage, value and recognise your achievements. You’re invited to talk, but there is no pressure–you set the pace. They help you develop support networks and coping strategies and look at your physical well-being, not just psychological. Issues of power and control were important in relationships with counsellors and therapists. For example, Jen spoke of feeling powerless to complain about what she considered an inappropriate approach to

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therapy because she was being sent by her boarding school; Hayley discussed being “kicked around like a football” between services, and her school counsellor discussing her problems with her parents, despite Hayley asking him not to. Jackie and Lara spoke of feeling like the therapist was the expert and they were “just” the patient, or as Jackie put it, that “you’re not an individual, you’re a disorder.” In contrast, several participants discussed eventually finding a counsellor that they were able to work with. These effective therapeutic relationships seemed to be characterised by an equal partnership, with participation in the process of therapy, such as choosing when and how to disclose abuse. DISCUSSION The topic of sexual abuse was not raised by the researcher; all prompting was kept to a minimum in order to allow participants to tell their own stories, except for clarification purposes. However, sexual abuse emerged as by far the most important factor identified, both quantitatively and qualitatively, when considering the participants as a group, although not all participants were survivors of abuse. The majority of participants (16 of 24) had been sexually abused during childhood. All of these women considered it to be the most important factor in their subsequent suicidal behaviour, although some noted that related factors exacerbated the abuse. In addition, two of the women who had not been sexually abused discussed their first experience of sexual intercourse as a precipitator of suicidal behaviour, due to the circumstances under which the experience occurred. In both cases, sexual experience was in conflict with their strongly held religious beliefs and alcohol consumption, suggesting that the experience was not fully consensual. The literature on childhood sexual abuse discussed depression and suicidal behaviour as possible outcomes (e.g., Boudewyn & Liem, 1995; Read et al., 2001; Rodriguez-Srednicki, 2001; Romans, Martin, & Mullen, 1997; Wagner & Linehan, 1994). While the literature on youth suicidal behaviour also lists sexual abuse as a risk factor (Ministry of Youth Affairs, Ministry of Health, & Te Puni Kokiri, 1998; Romans et al., 1995), it is not given the importance that this study suggests it deserves. This may be because much of the literature is not gender-differentiated and females are more likely to be victims of sexual abuse than males.

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In addition to sexual abuse itself, many of the participants who were survivors of abuse spoke of exacerbating factors, most commonly around disclosure of the abuse. As Muir (1993) and Myer (1985) discussed, it is not uncommon for disclosure of abuse to be met with unsatisfactory responses, if not outright denial, and this was the case for several participants in this study. This resulted in rejection of the abuse survivor, and in some cases continuation of the abuse. Other participants were believed and supported when they initially disclosed sexual abuse, but found the process of taking criminal proceedings against the abuser traumatic. In other cases, disclosure of abuse resulted in disclosures by other family members, with major family upheaval ensuing. Some participants suggested that the results of disclosure were more traumatising than the abuse itself. This finding suggests that a history of sexual abuse gave rise to another risk factor: unsupportive reactions to disclosure. Although the sexual abuse literature does suggest that survivors are at increased risk of suicidal behaviour (e.g., McCauley et al., 1997; Rodriguez-Srednicki, 2001), it would seem that most survivors of sexual abuse do not resort to suicidal behaviour. However, this study strongly suggests that females who engage in suicidal behaviour are likely to have been sexually abused. This finding concurs with that of Romans et al. (1995). It should be noted, however, that there is a danger in assuming that all suicidal females have been sexually abused. Several participants spoke of being pressured to disclose abuse before they were ready, and the negative impact this had on them. While many participants acknowledged the importance of dealing with experiences of sexual abuse, the necessity of allowing the abuse survivor to control the disclosure process was stressed. All the participants who had been sexually abused spoke about this passionately. It is unclear why some girls and young women who have been sexually abused go on to engage in suicidal behaviour, and others do not. However, the presence of protective factors such as a supportive environment generally, and strong self-esteem and appropriate response to disclosure may well explain this divergence. It appears from this study that disclosure of sexual abuse and the ways that disclosures are dealt with play a vital role in determining the course of related depression and suicidality. While responses to disclosure are discussed in the literature (Candib, 1999; Holguin & Hansen, 2003), a possible relationship between the handling of disclosures and suicidal behaviour does not appear to have been examined. While agreeing with Romans and colleagues’ (1997) finding that sexual abuse alone is neither necessary nor sufficient in itself to lead to suicidal behaviour, the finding that the majority of participants felt that if they had not been sexually

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abused or if their disclosures of sexual abuse had been handled appropriately they would not have become suicidal is particularly noteworthy. NOTES 1. Common definitions include “any unwanted or negative sexual experience in childhood and/or early adolescence” and “any act or acts that result in the sexual exploitation of a child or young person, whether consensual or not.” 2. “[W]hen a person under the age of eighteen years has sexual contact with a person at least five years older; the sexual contact is abusive when it is unwanted or coercive” (p. 2). 3. All names have been changed.

REFERENCES
Anderson, J., Martin, J., & Mullen, P. (1993). Prevalence of childhood sexual abuse experiences in a community sample of women. Journal of the American Academy of Child and Adolescent Psychiatry, 32(5), 911-919. Boudewyn, A. C., & Liem, J. H. (1995). Childhood sexual abuse as a precursor to depression and self-destructive behavior in adulthood. Journal of Traumatic Stress, 8(3), 445-459. Burns, R. B. (1994). Introduction to research methods (2nd ed.). Melbourne, Australia: Longman Cheshire. Candib, L. M. (1999). Incest and other harms to daughters across cultures: Maternal complicity and patriarchal power. Women’s Studies International Forum, 22(2), 185-201. Fergusson, D. M., Lynskey, M. T., & Horwood, L. J. (1996). Childhood sexual abuse and psychiatric disorders in young adulthood: Part I: The prevalence of sexual abuse and the factors associated with sexual abuse. Journal of the American Academy of Child and Adolescent Psychiatry, 34(10), 1355-1364. Gladstone, G. L., Parker, G. B., Mitchell, P. B., & Malhi, G. S. (2004). Implications of childhood trauma for depressed women: An analysis of pathways from childhood sexual abuse to deliberate self-harm and re-victimisation. The American Journal of Psychiatry, 161(8), 1417-1426. Goodyear-Smith, F. (1993). First do no harm: The sexual abuse industry. Auckland, New Zealand: Benton-Guy Publishing. Gould, M. S., King, R., Greenwald, S., Fisher, P., Schwabstone, M., Kramer, R., et al. (1998). Psychopathology associated with suicidal ideation and attempts among children and adolescents. Journal of the American Academy of Child and Adolescent Psychiatry, 37(9), 915-923. Holguin, G., & Hansen, D. J. (2003). The “sexually abused child”: Potential mechanisms and adverse influences of such a label. Aggression and Violent Behavior: A Review Journal, 8(6), 645-670.

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McCauley, J., Kern, D. E., Kolodner, K., Dill, L., Schroeder, A. F., DeChant, H. K., et al. (1997). Clinical characteristics of women with a history of childhood abuse. Journal of the American Medical Association, 277(17), 1362-1368. Ministry of Health. (1998). Our children’s health: Key findings on the health of New Zealand children. Wellington: Author. Ministry of Youth Affairs, Ministry of Health, & Te Puni Kokiri. (1998). In our hands: New Zealand youth suicide prevention strategy. Wellington: Author. Muir, N. A. (1993). Prevalence, risk factors and disclosure in child sexual abuse. Unpublished Master’s thesis, University of Waikato, Hamilton. Muir, N. A. (2001). Telling secrets: The process of disclosure for women with stigmatised experiences. Unpublished doctoral dissertation, University of Waikato, Hamilton. Mullen, P. E., Martin, J. L., & Anderson, J. C. (1996). The long-term impact of the physical, emotional and sexual abuse of children: A community study. Child Abuse and Neglect, 20(1), 7-21. Myer, M. H. (1985). A new look at mothers of incest victims. Journal of Social Work and Human Sexuality, 3, 47-58. Polusny, M. A., & Follette, V. M. (1995). Long-term correlates of child sexual abuse: Theory and review of the literature. Applied and Preventive Psychology, 4, 143-166. Read, J., Agar, K., Argule, N., & Aderhold, V. (2003). Sexual and physical abuse during childhood and adulthood as predictors of hallucinations, delusions and thought disorder. Psychology and Psychotherapy: Theory, Research and Practice, 76, 1-22. Read, J., Agar, K., Barker-Collo, S., Davies, E., & Moskowitz, A. (2001). Assessing suicidality in adults: Integrating childhood trauma as a major risk factor. Professional Psychology: Research and Practice, 32(4), 367-372. Rodriguez-Srednicki, O. (2001). Childhood sexual abuse, dissociation, and adult self-destructive behavior. Journal of Child Sexual Abuse, 10(3), 75-90. Romans, S. E., Martin, J. L., Anderson, J. C., Herbison, G. P., & Mullen, P. E. (1995). Sexual abuse in childhood and deliberate self-harm. American Journal of Psychiatry, 152(9), 1336-1342. Romans, S. E., Martin, J., & Mullen, P. (1996). Women’s self-esteem: A community study of women who report and do not report childhood sexual abuse. British Journal of Psychiatry, 196(6), 696-704. Romans, S. E., Martin, J. L., & Mullen, P. E. (1997). Childhood sexual abuse and later psychological problems: Neither necessary, sufficient nor acting alone. Criminal Behaviour & Mental Health, 7(4), 327-338. Saunders, B. E., Villeponteaux, l. A., Lipovsky, J. A., Kilpatrick, D. G., & Veronen, L. J. (1992). Child sexual assault as a risk factor for mental disorders among women. Journal of Interpersonal Violence, 7(2), 189-204. Sedney, M. A., & Brooks, B. (1984). Factors associated with a history of childhood sexual experience in a nonclinical female population. Journal of the American Academy of Child Psychiatry, 33, 215-218. Silverman, A. B., Reinherz, H. Z., & Giacona, R. M. (1996). The long-term sequelae of child and adolescent abuse: A longitudinal community study. Child Abuse and Neglect, 20(8), 709-723.

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Stepakoff, S. (1998). Effects of sexual victimization on suicidal ideation and behavior in U.S. college women. Suicide and Life-Threatening Behavior, 28(1), 107-123. Vajda, J., & Steinbeck, K. (2000). Factors associated with repeat suicide attempts among adolescents. Australian and New Zealand Journal of Psychiatry, 34, 437-445. Wagner, A. W., & Linehan, M. M. (1994). Relationship between childhood sexual abuse and topography of parasuicide among women with borderline personality disorder. Journal of Personality Disorders, 8(1), 1-9.

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