BritishJournal of Psychiatry(1992),160, 261—265

Childhood Reported

Sexual Experiences with Adults by Female Psychiatric Patients

R. L. PALMER,

D. A. CHALONER

and A. OPPENHEIMER

A group of 11 5 female psychiatric in-patients and out-patients were studied,using a self report questionnaire followed by interview, for evidence of childhood sexual activity with adults. About half of the sample reported some childhood sexual experience, ranging from full sexual intercourse to sexual suggestions. Future research should study the possible role of such experienceinthe genesis of subsequent psychiatric disorder.

In recent

years increased

attention

has been paid to

the issue of sexual contact between children and adults. There has been an increase in reports of recent abuse and a number of studies have documented the recollections of adults about experiences in their childhood (Finkelhor, 1979, 1984, 1986; Russell, 1983; Kercher & McShane, 1984; Baker & Duncan, 1985; Nash & West, 1985). It is clear that sexual contact between children and adults is not un common. In general, the use of the term sexual abuse to denote these experiences would seem to be

justified. Estimating true rates is difficult because of problems of selection of study populations, of definition and of the possibility of some false reporting by subjects. It has sometimes been assumed that

such

false

reporting

would

be

mainly

the

reporting of fantasy as reality (false positives), but in practice the failure to report real experiences (false negatives) would seem to be at least as likely. The long-term consequences of childhood sexual experiences with adults have been reported to include anxiety, deliberate self-harm, depression, difficulties in interpersonal relationships, eating disorders, poor self-esteem, prostitution, and sexual dysfunction (James

& Meyerding,

1977; McGuire

& Wagner,

1978;

Sibert & Pines, 1981; Gelinas, 1983; Oppenheimer eta!, 1985; Herman et a!, 1986; Browne & Finkelhor, 1986; Wyatt & Johnson-Powell, 1988; Palmer et al,

1990). The concept of post-traumatic stress disorder is of interest with respect to reactions to childhood sexual experiences (Finkelhor, 1986) but may be

inadequate to describe the full range of consequences which have been described. between childhood

The nature of the links

sexual experiences

that four factors,

a long history, in which the ideas of Freud are of great importance (Freud, 1896, 1914). As is well known, Freud at first suggested that adult neurosis was caused by childhood seduction and then changed his mind to think of the ideas of his patients

as being

rooted in universal fantasies which were part of psychological development. This view was of great importance in the creation of psychoanalytic theory but also tended for many years to fog the issue of whether actual sexual abuse in childhood might play a part in promoting some adult mental disorder (Masson, 1984). Reports of such experiences were often greeted with sophisticated scepticism. Recently, there have been a number of studies reporting accounts of childhood sexual experiences given by various samples of psychiatric patients (Lukianowicz, 1972; Molnar & Cameron, 1975; Rosenfield, 1979; Carmen et a!, 1984; Oppenheimer eta!, 1985; Jacobsen & Richardson, 1987; Metcalfe et a!, 1990; Palmer et a!, 1990). Unfortunately, the experiences have sometimes been poorly described and variously defined, and the studies have not been controlled. However, two recent community studies have been controlled and support the idea that there may be an association between reports of abuse and measures of current psychopathology (Mullen et a!, 1988; Burnham et al, 1988). This paper reports a study of adult female psychiatric patients. It is, as yet, uncontrolled but employs a standard method of inquiry and a precise classification of reports.

with adults and

later problems is unclear, but Finkelhor proposed

patienthood as an adult are more likely in individuals abused as children. Speculation about this link has

Method

(1988) has

namely traumatic

sexual

The subjects taking part in the study were 115 female psychiatricpatients attending three hospitals in Leicestershire. Both in-patients and out-patients were included in the study. The patients were aged between 16 and 49 years. Patients who were currently psychotic, illiterate, suffering from

isation, betrayal, stigmatisation and powerlessness, are likely to be among the relevant noxious influences. Whatever the mechanism, it is certainly plausible that mental disorder and psychiatric 261

PALMER ET AL

262

an organic psychosis, or whose English was poor, were excluded from the study. Patients with clinical eating disorders are also excluded from this study and have been reported separately (Palmer et al, 1990). Diagnoses were made using ICD—9(World Health Organization,

1978), either on the basis of the case notes

alone, or following additional discussion with the relevant clinician. All female patients in the relevant age group, attending

the out-patient departments, were asked to take part in the study. Each of the clinics used served a geographically

defined population, with the exception of the academic clinics. The voluntary nature, confidentiality, and general format of the investigation were explained to the patient, including that the study involved recollections of childhood experiences, and that at the time of completing the questionnaire “¿its more detailed nature would be explained to them―, that they would complete

the questionnaire alone, and that after completion they would be interviewed. Female in-patients within the age limits were approached

in a similar

way, if they were

not currently psychotic and were judged to be well enough to take part by the relevant medical and nursing

Table 1 Reported events with childhood categories arranged according to a hierarchy of ‘¿seriousness' of the sexual act Subject 13_151Full

aged under 131Subject

aged

•¿1

intercourse714Subject sexual withgenitals having oral contact others42Subject of togenitals10Intercourse receiving oralcontact penetration72Subject without genitals10Other touching other's genitals26Subject touching subject's

sexually10Other fondling other sexually62Subject fondling subject genitals10Witnessing exposingown actsbetween abusivesexual others02Other subject55Kissing exposing genitals to sexually20Request andhugging sexual12Total3835 todo something

staff.

if the patients agreed to take part in the study they were asked to complete the Sexual Life Events Inventory,

a self-reportquestionnaire.The questionnairewasadapted from that used by Finkelhor in studies of students (Finkelhor, 1979) and is the same instrument used by the present authors in studies of clinically eating-disordered patients (Oppenheimer et a!, 1985; Palmer et a!, 1990) and of male psychiatric patients (Metcalfe et a!, 1990). The patients were asked to describe, by selectingappropriate responses,

events

occurring

before

the age of 13 years with

someone over 16 years old, and between ages 13 and 15 inclusive with someone at least five years older. They were asked to describe any event which they construed as sexual. In each age category, subjects could describe up to three events or series of events with the same person. The description

of each event

included

details

of the patient's

age at occurrence, the age of the other person involved, the relationship with the other person, the nature of the event, the use of force or threat, her emotional and sexual responses and the approximate number of times or length of time that such a relationship

continued.

The categories of the events are listed in Table 1. For the purpose of analysis, the types of event were arranged

in a hierarchy

of

‘¿seriousness'. However,

no

precise prediction of seriousness of effect is implied by the ordering.

After completion of the questionnaire, all subjects were immediately interviewedand asked to discuss the information described in the questionnaire. This discussion allowed both clarification and elaboration of response together with personal support for those subjects who were distressed by the revelation of painful memories. Following completion of the questionnaire and initial discussion, some

patients were offered further opportunity to discuss the events which they had disclosed, and indeed, some patients asked for such help. With the agreement of the patient, any relevant information was passed to her psychiatrist.

4

Results Of the 152women approached, 115co-operated with the study.

The 37patientswhorefusedto take part in the studywere aged 18-45 years. Their diagnoses were: schizophrenia, II; manic—depressivepsychosis, 20; anxiety, 1; obsessive compulsive neurosis, 1; chronic pain, 1; reactive depression,

I ; personality disorder, 2. The reasons given for not completing the questionnaire, or for not taking part in the study, were that it would take too long; that their childhood was too painful to remember; that the patient felt too ill; that nothing unhappy had happened in their childhood; that they did not want to put it on paper; and that they could not remember their childhood. Most refusals occurred before the specific and sexual nature of the inquiry was revealed. However, three patients refused to take part when they realised the nature of the questionnaire. One of these patients actually completed the questionnaire but left the clinic without allowing it to be discussed fully or the questionnaire to be seen. She admitted that she had sexually abusive experiences with an older brother and stepfather in her later childhood. No one knew of these events, and she was unwilling to discuss them with anyone because it was, she said, “¿too awful―.The two other patients refused to complete the questionnaire when they were shown it because they said they did not want to think about abusive experiences with adults during their child hood, which both admitted had taken place. Both found

them too distressing to discuss. These subjects were not included in the study. The mean age of respondents was 30 years (s.d. 2.0, range 16—49).At the time of the study 34 (29.6%) described themselves as unemployed, 32 (27.8%) as housewives and 49(42.6%) were employed. Social class, defined according

CSA IN FEMALE PSYCHIATRIC PATIENTS Table 2 ,

Social

class

of

abused

subjects

by

father's

occupation

263

Table 3 Rates of abuse in each diagnostic category

—¿

using Registrar General's classification DiagnosislCDTotal no. in

Social classTotal

no. with in sampleNo.criterion sexual

abused each

no.

classI14964.3II211152.4Ill whole sampleTotalabused% events%Manic-depressive (nm)191052.6Ill (ml251456.0IV14642.9V3133.3Unknown19631.6

psychosis296361850Neurotic disorders300361850Schizophrenia295and other2975240psychoses298Personalitydisorders301261557.6Sexual

to the Registrar

General's

was rated for the employed

Classification

of Occupations,

subjects as follows: Class II,

6; Class III (non-manual), 19; Class III (manual), 8; Class

dysfunction3026350Other (alcohol,psychogenic painetc.)6116.6Total11557

IV, 4; and Class V, 9. (Threeemployedsubjectscould not be defined.) Subjects were also classified according to their father's occupation, which may be more relevant for a study of

reports

of

classification

childhood

events.

The

results

of

this

are given in Table 2.

six

Events before age 16 which fulfilled the criteria were reported by 57 subjects (49.6%). Events at age 12 or below

@

(14.6%)

were

family

members

(two

fathers,

two

stepfathers and two uncles). The others were strangers in 10 cases (24.4%) and a known person in the remainder. The reported event was described as having been initiated

had occurred in 38 (33%), and 35 (30.4%) reported events between the ages of 13 and 15. Twelve subjects (l0.4°lo) solelyby theotherpersonin 56%of cases,as havinginvolved some physical force in 56% of cases, and with verbal threats reported events in both categories and, in all, 19 sub in 51% of cases. Events in this older category were reported jects reported more than one set of events, that is, events with different people. The nature of the most ‘¿serious' event as having been associated with moderate or severe distress reported by each subject within each age category is shown in 70.7% of cases and with some sexual pleasure in 10%. in Table 1. There was no evident association between category of For the 50 events before age 13 reported by 38 subjects, psychiatric diagnosis at the time of study and overall rate there were seven instances of sexual intercourse with full of reports of criterion events (Table 3). Likewise, there was penetration,

five

intercourse

without

of

oral

sex

and

full penetration.

a further

seven

of

For 31 of these 38

subjects there was bodily contact of a sexual nature. On average, the other person involved was 21.8 years older than the subject (range 5—62years) and in all but two cases was

no association between reporting of events and classification of the subject's father (Table 2).

social

Discussion

male. This person was a family member in 23 cases (46°lo) About half of this series of women undergoing two brothers, one psychiatric treatment reported childhood sexual grandfather, four uncles, one cousin, one brother-in-law, activity with adults. Many of the events described (including nine fathers, two stepfathers,

and the two female others were both sisters of the subjects).

The other person was described as a stranger in 13 cases and, of the rest, only one was described as the subject's

been distressing at the time of occurrence. Most were abusive in the sense that they involved the exploitation of children for the gratification of adults, who were described as having been initiated solely by the other person usually much older. Betrayal of trust was evident in in 81% of cases, and as having involved some physical force in 42% of cases. Moderate or severe distress at the many cases and the other person involved was often time was associated with 42 events (80%) and only three a family member, especially in the younger age (6%) were recalled as having been associated with any sexual group. In almost every case, the other person was pleasure for the subject. male. For the 41 events at ages 13—15 reported by 35 subjects, The rates of childhood sexual experiences with adults (sexual relationships continuing from below 13 to 13—15 recalled by the female psychiatric patients in this were not included), there were 14 instances of full study seem markedly higher than those reported in intercourse, two of oral sex and two of intercourse without full penetration. For 26 of these 35 subjects there was bodily studies of women drawn from non-psychiatric popu lations. Mostly, such studies report rates only about contact of a sexual nature. On average the other person involved was 18.3 years older (range 5 to 47 years) and all one-third as high (Russell, 1983; Kercher & McShane, were male. By contrast with the younger age group, 11 1984;Finkelhor,1984;Baker & Duncan, 1985), (26.5%) of the others were described as ‘¿friends' and only although Nash & West (1985) did find comparable ‘¿ friend'

r

were far from trivial and were remembered as having

at

the

time

of

the

event.

The

reported

event

was

264

PALMER ET AL

overall rates in general practice (GP) patients and students. However, only 2.2°loof their subjects (1.8% GP patients; 3.3% students) had experienced sexual intercourse with penetration by an adult before they were 16 compared with 14.8% of the subjects of the present study. (It is possible that some of these events may have involved anal penetration.

and, therefore, a bias specific to sexual matters is unlikely. The three potential subjects who did refuse

The questionnaire did not distinguish between anal

refusers were assumed to have had no such experiences, an extreme assumption in view of the specific refusers noted above. It seems possible to conclude with some confidence that, at least in this population, between one-third and a half of female psychiatric patients report sexual experiences with adults in their childhood. The possible role of such experiences in the genesis of later psychiatric disorder is an appropriate area for continuing research. In the light of present findings,

and vaginal intercourse

but subsequent

discussion

with subjects revealed that some found the distinction

impossible to make when recalling early childhood memories. However, no case of unequivocal anal intercourse was described.) It seems that the present series mainly

reports

the more

‘¿serious'events.

At

present, any comparisons are imprecise and uncertain because of differences of definition and method between studies. Greater certainty must await the comparison of groups using the same definitions and the same method. That higher rates in psychiatric groups might reflect a greater willingness to divulge sensitive

or painful

memories

in a clinical

setting

is

4

because of the particular nature of the study were all probably abused as children, as already described. In the terms of the study, the overall rate of women reportingsexualeventswith adultsin childhood

would have fallen from 49.6% to 37.5% if all

it would

seem sensible

to inquire

about

childhood

sexual experiences in the assessment of most female psychiatric patients presenting with functional disorders.

possible, but there is no strong evidence to support such a view.

Generally,

the accounts

given

by the

Acknowledgements

subjects of the present research were believable and there seemed to be no reason to suppose that they were reporting fantasies. The detailed interviewing

of all subjects overcame the possible problems of using self-report methods alone. It is plausible that experiences such as those reported by many of the subjects of this study could have lasting effects of a kind which might increase vulnerability to adult psychiatric illness. Problems of self-esteem, trust and interpersonal functioning could be intervening variables. Neurotic disorder and personality problems might be thought of as most likely to be promoted in this way, although no clear relationship between events and diagnosis emerged in this study. However, the numbers in each diag nostic group were small, and those refusing to take part in the study seem to have been more likely to have had a psychotic diagnosis, thus introducing a possible bias. It is necessary to look for other sources of possible bias in the whole study. Thus it is to be noted that about a third of the subjects gave information leading their parental social class to be rated as I or II, which is rather higher than expected; and which may suggest that the sample was in some way unrepresentative. However, there would be no clear reason why some selection on this basis would lead to inflated rates of reported experience. More serious is the possible significance of the loss of the quarter of potential subjects who declined to take part in the study. However, most refusers declined to take part before they had been told of the nature of the inquiry

This study was supported by a grant from the Trent Regional Health Authority. We would like to thank the consultant psychiatrists who allowed access to patients under their care and especially we thank the subjects themselves who allowed us to explore and document their sometimes painful memories. Mrs Sandra Linthwaite deciphered, organised, skill.

and

prepared

the manuscript

with characteristic

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*R. L. Palmer, FRCPsych, Senior Lecturer in Psychiatry, University of Leicester, and Honorary Consultant

Psychiatrist, Leicester Health Authority; D. A. Chaloner, MRCPsych, Consultant Psychiatrist, formerly ResearchRegistrar, Leicester Health Authority; R. Oppenheimer, BSc,formerly Senior Social Worker (Teaching), Leicestershire Social ServicesDepartment and Leicester General Hospital *correspondence: University Department of Psychiatry, Leicester General Hospital, Gwendolen Road, Leicester LES 4PW

Childhood sexual experiences with adults reported by female psychiatric patients. R L Palmer, D A Chaloner and R Oppenheimer BJP 1992, 160:261-265. Access the most recent version at DOI: 10.1192/bjp.160.2.261

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