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Keywords:

  • Child Sexual Abuse;
  • Sexual Function;
  • Risky Sex;
  • Theory;
  • Sexual Dysfunction;
  • Psychophysiology

ABSTRACT

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

Introduction.  Sexual problems in women with a history of child sexual abuse (CSA) are relatively common but only a few studies have attempted to explain the mechanisms of these problems. Given the potential for a variety of factors associated with sexual problems in CSA survivors, the field needs a theoretical model to explain these difficulties.

Aim.  The main aim of this article was to illustrate a theoretical model to understand sexual problems in CSA survivors. Sexual problems are here grouped into hyposexual and hypersexual. A review of empirical studies that support this model is presented. A second aim was to discuss the definition of CSA adopted in research projects.

Methods.  Results from studies targeting psychophysiologic, affective, and cognitive sexual responses are discussed.

Main Outcome Measures.  Vaginal photoplethismography, sexual self-schemas, and implicit sexual associations to sexual stimuli were the focus of the studies reviewed.

Results.  These studies showed that during the exposure to sexual stimuli, CSA survivors experienced more inhibitory responses and less excitatory responses than women in the comparison groups. On the other hand, in situations when sexual stimuli were not present, CSA survivors showed a greater excitation of sexual responses than women in the comparison groups. Additionally, CSA survivors showed a potential difficulty inhibiting intrusive sexual thoughts.

Conclusions.  The model shows promising qualities to adequately explain the hypo- and hypersexuality of CSA survivors. The advantages of this model over others include the ability to guide the selection of cognitive and behavioral interventions for patients presenting for treatment. Rellini A. Review of the empirical evidence for a theoretical model to understand the sexual problems of women with a history of CSA. J Sex Med 2008;5:31–46.

Child sexual abuse (CSA) is associated with a number of psychiatric problems including post-traumatic stress disorder (PTSD), eating disorders, major depression, sexual dysfunction, and borderline personality disorder. Much research has focused on the psychiatric function of women with a history of CSA, but sexual function has received only limited attention. This is unfortunate because sexual function is an important aspect of women's quality of life, quality of relationships, and sense of self [1]. Additionally, recent studies suggest a mediating effect of sexual dysfunction in the relationship between CSA and risky sexual behaviors [2]. Given these findings, a greater understanding of the sexual difficulties of CSA survivors could help mental health providers develop interventions to prevent revictimization occurring during risky sexual behaviors. In particular, identifying and investigating potential mediators and moderators of sexual problems in this population can inform the development of prevention and treatment interventions.

To provide a framework to better understand the sexual problems of CSA survivors, an in-depth discussion of the characteristics of this population is followed by the illustration of a theoretical model for the sexual responses of women with and without a history of CSA. A review of five studies provides initial evidence for the usefulness of this model to understand the sexual problems of CSA survivors. Finally, a discussion of the clinical implications and the limitations of this model is presented along with suggestions for future research.

The Sexuality of CSA Survivors

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

Information available on the sexuality of CSA survivors is mostly derived from incidence and prevalence studies. Overall, results identified a larger percentage of sexual dysfunction in CSA survivors compared to women with no history of CSA. The effect sizes are usually small and the results are confusing and hard to interpret, mostly because of the heterogeneity of individuals grouped under the CSA definition and the diverse sexual problems studied. A thorough discussion of this literature is beyond the scope of this article as there are a number of recently published reviews of this topic [i.e., 3,4]. However, a clear statement of the sexual problems and the population addressed in this model, along with the identification of the rationale for choosing this focus, is necessary for the appropriate generalizability of the results reviewed.

First of all, the model presented here focuses on two general types of sexual dysfunction commonly reported by CSA survivors, which we refer to as hyposexuality and hypersexuality. Hyposexuality comprises problems with avoidance of sexual activities, hypoactive sexual desire, female sexual arousal disorder, and anorgasmia. Hypersexuality involves the tendency to engage in sexual activities impulsively with strangers or in risky situations and without using protection. At times, the literature refers to this type of hypersexuality as compulsive sexual behaviors, other times as addictive sexual behaviors. Yet other research supports the conceptualization of these sexual problems as impulsive sexual behaviors [5]. Impulsivity is perhaps the concept that fits best the experience of this population that is at high risk for a number of impulsive behaviors. However, the scarce information available on the motivation and the precedents of these sexual behaviors prevents making a decision between compulsive, addictive, or impulsive behaviors. Therefore, the more general term of hypersexual behaviors is used in this manuscript.

One important aspect of the sexual distress of CSA survivors is that problems with hypo- and hypersexuality can coexist or be experienced in quick succession within the same individual. For example, a participant in a study on CSA (qualitative data not presented here) felt that her sexuality was out of control for most of her life. For many years, she engaged in sexual activities almost impulsively and put herself in potentially dangerous situations. A few months after beginning an intimate, committed relationship she developed the opposite problem and became hyposexual. Although this is only the experience of one individual, it provides an illustration of how hyper- and hyposexuality can co-occur.

Looking for a Homogenous Group of CSA Survivors

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

Studies on CSA have been frequently criticized because of the lack of a clear definition of the population studied [3]. Specifying the characteristics of the sample recruited is crucial because the term CSA is very broad and includes an eclectic group of women that have little in common. This heterogeneity leads to conflicting results in the literature and a loss of credibility in the topic. The method selected to narrow the sample to a more homogenous group of CSA survivors dictates the power of the study, the generalizability of the results, and therefore the applicability of the results to the clinical population. One way to select a more homogeneous group of CSA survivors is by identifying specific characteristics of CSA that are in common among survivors with sexual problems (e.g., age at time of the abuse, relationship with the perpetrator, use of force during the abuse, etc.). This conceptualization is based on the assumption that similar experiences affect people's functioning in similar ways. Alternatively, a greater homogeneity can be reached by selecting participants on the basis of the type of sexual problems experienced during adulthood. This method is based on the assumption that different experiences can lead to the same outcome; thus, we would expect that all people with anorgasmia will show impairments in the same mechanisms independently from what caused the anorgasmia. At the present time, the most appropriate way to conceptualize the sexual problems of CSA survivors is still to be determined. Perhaps, a combination of both a distinction in characteristics of the abuse and type of sexual problem experienced during adulthood is the best solution.

To increase our understanding of CSA homogeneity based on the type of experiences reported, a comprehensive assessment of abuse characteristics was conducted on 699 female college students [6]. Sexual distress was more strongly associated with reports of multiple abuses, the presence of vaginal penetration during the abuse, and a familial relationship with the perpetrator. Interestingly, women who reported sexual abuse before age 12 did not differ from women who were abused before age 16, suggesting that age when CSA started is less of a factor in the development of adult sexual problems than initially hypothesized. The retrospective report of fear at the time of the event was also not associated with the amount of distress experienced during adulthood.

Taken together, these results suggest that studies on sexual problems in women with a history of CSA should adopt a definition of CSA that includes at least one of the following: the presence of multiple incidents of abuse, the report of vaginal penetration at the time of abuse, and a familial relationship between abuse survivor and perpetrator. This suggestion does not claim that women with different types of sexual abuse do not develop sexual problems related to the abuse, but rather provides a framework for researchers to target a more homogenous subset of CSA survivors that is at a higher risk for developing sexual dysfunction during adulthood.

A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

A second common criticism of the literature on sexual function in CSA survivors is the lack of a guiding theoretical framework. The theoretical frameworks that have been used to explain sexual function in sexual abuse survivors are few and mostly derived from the trauma or the human development fields [7]. The presence of countless factors potentially associated with sexual function in sexual abuse survivors, and the lack of theoretical framework to investigate this topic has lead to an eclectic and confusing picture of this phenomenon with limited clinical relevance.

The main problem of the existing models is the omission of the physiologic and biologic aspects of female sexual response. Trauma-focused models assume that for all individuals, the sexual abuse was traumatic. Trauma is defined by the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (DSM-IV) as an experience that caused sudden feelings of fear for one's life, horror, and hopelessness. However, while many CSA survivors often report such feelings, many do not. Indeed, of those women who experienced unwanted sexual activities before the age of 16, only 39.3% reported fear or horror at the time of the event [6]. Fear at the time of the event was not predictive of the sexual distress experienced during adulthood [6], indicating that it is not necessary for the abuse to meet the criteria of trauma to be associated with sexual problems in adulthood.

Compared to the trauma model, the developmental model of sexual dysfunction in CSA survivors provides a greater picture of the potential interaction between the environment and the characteristics of the abuse. The inclusion of environmental and developmental characteristics is more conducive to explaining why only some women develop sexual dysfunction during adulthood. Also, this model takes into consideration the relationship characteristics, which are an intrinsic aspect of sexuality. However, this model is not able to fully explain why CSA survivors complain of hypo- and hypersexuality. In an attempt to provide an overarching framework that incorporates biologic and individual differences in the explanation of the sexual problems of CSA survivors, a model of the sexual response is proposed here.

Given that women's sexual function is a multifaceted phenomenon [8] and provided that sexual abuse can have an impact on multiple processes, the model favors the interaction of biologic, cognitive, and affective processes. This model is a combination and adaptation of two well-known models for sexual response commonly used in the field of sexuality: (i) the information processing model (IPM) for sexual response [9] and (ii) the dual-control model (DCM) for sexual arousal [10].

According to the IPM, sexual stimuli are processed at the unconscious level and, through the activation of attention and other cognitive processes, they prime the individual to sexual arousal. A series of studies on stimuli exposed above and below the consciousness threshold has provided convincing evidence for this model's usefulness in identifying mechanisms outside people's awareness and control [11].

The DCM model is primarily concerned with responses to sexual stimuli based on automatic and nonvolitional characteristics of the individual. This model conceives the experience of subjective sexual arousal (i.e., the feeling of being aroused) and physiologic sexual arousal (i.e., the physiologic responses that includes vasoengorgement in the genitals) as the summation of all positive and negative responses to sexual stimuli. For example, in the adaptation of the DCM to women, a sexual video may be perceived as not sexually arousing because, although viewing a couple having sex is arousing, the female actress was obviously pretending to enjoy herself and this inhibited feelings of sexual arousal. In this example, attention to the environmental information (i.e., the actress) outweighed the arousing response to the couple having sex, and the result was a lack of the sensation of sexual arousal.

The two models are not mutually exclusive but can complement each other and the model proposed here is one way in which this can be accomplished. One advantage of this model over previously presented theories of sexual arousal among CSA survivors is the greater inclusion of knowledge derived from studies on women's sexual responses. In particular, the model distinguishes between circuits that affect physiologic and subjective sexual responses and this enables the differentiation between mental and genital sexual arousal problems reported by women. This model also allows for the explanation of how impairments can lead CSA survivors to both hyper- and hyposexuality. Moreover, this model allows for independence between factors that affect physiologic and affective responses to sexual stimuli and this permits the explanation of incongruence within an individual, e.g., high physiologic sexual arousal in the presence of low subjective sexual arousal. Indeed, the disconnection between body and mind and the often reported dissociation during sex reported by CSA survivors may be a product of the independence between physiologic and mental responses to the sexual stimuli. Finally, the model includes the relevance of explicit and implicit sexual memories, which can explain the interaction between automatic biologic sexual responses and the contextual factors including relational characteristics.

First-Order Processes

As illustrated in the model presented in Figure 1, when a woman is exposed to sexual stimuli, there are two stages for stimuli processing: first-order (O1) and second-order (O2) processes. First-order processes are quick, automatic responses that occur at the basic perceptive level, are partially or completely outside awareness, and are nonvolitional. First-order processes are comparable to a startle response to a loud noise. They impact physiologic, affective, and cognitive responses through the activation of implicit sexual memories. Spiering and colleagues [12] defined implicit sexual memories as memories not available to consciousness such as innate sexual reflexes, learned sexual scripts, and classically conditioned sexual responses. According to the IPM, when stimuli match sexually implicit memories, they are perceived as sexually relevant and proceed to activate physiologic sexual responses. The modified model presented here proposes that implicit sexual memories can impact sexual responses by also activating affective and cognitive responses. This hypothesis finds support in the studies by Lang [13] that show a priming of emotional response during first-order processes. To illustrate this point, a woman may have learned that masturbating is shameful because of a childhood experience when she was punished for masturbating. This woman may not think that masturbation itself is shameful and may be sexually emancipated, but, despite her explicit beliefs, the affective response “shame” may be implicitly activated during masturbation. The sexual memory in this example is activated by the act of masturbation and the cognitive and affective associations activated during masturbation are the responses that match with the implicit sexual memory.

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Figure 1. The sexual response model. Illustration of the contribution to subjective and physiologic sexual arousal by physiologic, affective, and cognitive responses derived from first-order and second-order processes.

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Based on the DCM, implicit sexual memories have the ability to either excite (in Figure 1 represented as “+”) or inhibit (in Figure 1 represented as “−”) the activation of physiologic, cognitive, and affective sexual responses. The summation of all the excitatory and inhibitory sexual responses determines the final experience of subjective and physiologic sexual arousal that are reported or observed in women. In Figure 1, the responses that affect subjective sexual arousal are represented as triangles, and the responses that affect physiologic sexual arousal are represented as octagons. The sum of the “+” and “−” triangles and octagons derived from the first-order (O1) and second-order (O2) processes dictates the subjective and physiologic sexual arousal. It is possible for a type of response to have an effect on physiologic sexual arousal, subjective sexual arousal, or both. For example, an implicit sexual memory can have an excitatory effect on genital vasoengorgement (physiologic response), at the same time it can activate sexual scripts (cognitive response), and positive emotions (affective response). Implicit sexual memories can selectively create excitatory and inhibitory responses. For example, an implicit sexual memory that pairs sexual stimuli with fear may activate the fight-or-flight response, facilitate genital vasocongestion, and can simultaneously excite negative affect and cognitive networks associated with sexual stimuli. According to this model, it is feasible for first-order processes of sexual stimuli to prime physiologic sexual arousal and at the same time illicit responses that inhibit subjective sexual arousal.

Second-Order Processes

Second-order processes (in Figure 1 abbreviated as O2) comprise higher level functions that are volitional, slower, and occur in full awareness. First-order processes (O1) influence second-order processes. For example, cognitive responses (i.e., recognition that the stimulus is sexual in nature) derived from first-order processes activate attention to the sexual stimuli, which are then perceived and processed by second-order processes [11]. The processing of sexual stimuli by second order is more complex than first-order processes because factors such as the context, current mood of the individual, cultural scripts, personal values, social norms, attitudes, and the view of the sexual self become part of the logarithm that produces cognitive, physiologic, and affective responses. Similarly to first-order processes, second-order cognitive, affective, and physiologic responses can either excite or inhibit physiologic and subjective sexual arousal. The summation of inhibitory and excitatory responses coming from both first-order and second-order processes provide the final experience of subjective and physiologic sexual arousal as illustrated in the top two ovals in Figure 1. An additional level of complexity during second-order processes is that the different types of responses can affect each other. For example, increased heart rate and genital sensations (physiologic response) may promote an increase in feelings of pleasure (affective response). The intricate relationship between cognitive, physiologic, and affective feedback loop has been carefully illustrated in the revised model of sexual function/dysfunction presented by Wiegel [14].

Responses derived from second-order processes can be independent from first-order processes. For example, a woman who automatically associates male genitalia with anxiety (O1 affective response) may still experience positive affect when her partner has an erection if she consciously perceives this as an indication of his desire for her (O2 cognitive and affective responses). In this example, the amount of inhibition (represented by “−” in Figure 1) is smaller compared to the amount of excitation (represented by “+” in Figure 1). Both excitatory and inhibitory physiologic responses can be produced during the second-order processes, but physiologic sexual arousal is mostly derived from first-order processes. Indeed, physiologic sexual arousal can occur at times when the individual's subjective experience of sexual arousal is inhibited [15].

Based on this model, it is reasonable to expect that sexual abuse survivors experiencing sexual difficulties may have learned to automatically pair sexual stimuli with fear (implicit sexual memories). This association activates the stress response that inhibits physiologic sexual responses because of the antagonistic action of the stress response to resource blood and oxygen to organs responsible for the fight-and-flight reaction. Moreover, CSA survivors may be experiencing a weaker automatic association between positive affect and sexual stimuli and a stronger association between negative affect and sexual stimuli. These associations may work parallel to each other to inhibit subjective sexual arousal.

In a woman experiencing impairments in second-order processes, her initial physiologic sexual response may be normal but may be quickly inhibited after the sexual stimuli enter consciousness. In CSA survivors, the types of second-order impairment that may affect their sexuality include the activation of negative sexual self-views, which may lead to negative affect. To cope with the negative affect, women may try to distract themselves from the stimuli, which can bring to a decrease in both physiologic and subjective sexual arousal. Alternatively, the activation of implicit and explicit sexual memories during nonsexual situations (e.g., at times of fear, loneliness, or humiliation) may create distress because of perceived incongruence with the context.

Empirical Studies

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

A series of studies have been used to test the empirical validity and feasibility of this model to explain the sexual difficulties specific to women with a history of CSA. This review is divided into studies that primarily addressed first- or second-order processes. However, it was often difficult to isolate first-order from second-order responses because of their interaction. Although the data presented in this review are promising, it should be noted that these are only initial results and further investigations are needed before this model can be refuted, modified, or accepted.

Participants

The following studies investigated sexual function in a sample of CSA survivors with relatively similar sexual experiences. The knowledge of those CSA characteristics associated with later sexual problems was not available at the time studies reviewed here were conducted; therefore, the selection of CSA characteristics was partially arbitrary. All participants were categorized as CSA survivors if they reported unwanted sexual experiences that included genital touching and/or penetration before the age of 16. Ideally, this definition would have included the frequency of the events and the presence of a familial relationship with the perpetrator. Because of this limitation, the women in these studies may create a group more heterogeneous than desired, thereby decreasing the ability to correctly reject the null hypothesis (type II error). Conversely, this greater heterogeneity increases the ability to generalize the results to a larger portion of women with a history of CSA.

Women in the comparison groups reported no history of unwanted sexual experiences and were age matched with the experimental groups. All women were recruited from the community in a medium-size, southwestern town in the United States. Also, in the majority of the studies, the participants were between the age of 25 and 35 because we were interested in assessing impairments in the sexual response not because of the lack of experience or to hormonal changes associated with perimenopause or menopause. The participants received financial compensation to take part of the studies and all signed a consent form that was approved by the Institute Review Board of the university where the studies were conducted. Because of the strong interest of the public in these studies, several women maintained in touch with the laboratory over the years and participated in more than one study. However, only three women participated in more than one study that investigated the same process (i.e., the same woman was not used to investigate different aspects of explicit cognitive processes or different aspects of physiologic responses). All but one study was conducted over the course of 5 years, from 2001 to 2006. For a review of the studies and their results, see Table 1.

Table 1.  Summary of empirical studies used to investigate the proposed model
ReferenceGroupsManipulationSignificant findingsNot significant findings
  1. CSA = childhood sexual abuse; PTSD = post-traumatic stress disorder; O1 = first order; IAT = implicit association test; O2 = second order; LIWC = Linguistic Inquiry Word Count.

[19]CSA + PTSD vs. CSA vs. control(O1) Activation of SNSSNS activation did not facilitate physiologic sexual arousal in CSA and CSA + PTSDNo differences in subjective sexual arousal
[21]CSA vs. control(O1) Measure of cortisol before and after exposure to erotic videoA subset of CSA survivors showed an increase in cortisol after the exposure to an erotic video.No groups difference: on average, all women showed slight decrease in cortisol after the exposure to an erotic video.
Increases in cortisol associated with higher scores in dissociation during sex with partner.
[24]CSA vs. control(O1) IATAll women showed a stronger association between romance and pleasure compared to sex and pleasure.CSA women did not show a difference in the association between sex and pleasure compared to neutral and pleasure.
Control women showed a stronger association between sex and pleasure compared to neutral and pleasure.
[27]CSA vs. control(O2) Sexual Self-Schema ScaleThe relationship between CSA and negative affect during sex with a partner mediated by romantic/passionate schema. This relationship was independent from depression and anxiety.No significant relationship between CSA and open/direct, or embarrassment /conservatism schemas.
[28]CSA vs. control(O2 and O1) Linguistic analysis (LIWC) of sexually relevant textCSA used less sex words in response to a picture pulling for sexual themes.No significant relationship between group differences in number of negative affect words when writing about sexual fantasies.
CSA used more negative affect words, less body words.
CSA used less positive affect words compared to the control when writing about sexual fantasies.
CSA used more sex words when writing about the neutral topic compared to the control.

First-Order Processes

Physiologic Response

Two physiologic systems were investigated for their potential role in the sexual response of CSA survivors: the sympathetic nervous system (SNS) and the hypothalamus–pituitary–adrenal (HPA) axis, also known as the stress response. The SNS has been widely investigated in both the sexual abuse and the sexual function literature. The stress response (HPA) has been the focus of the sexual abuse literature but received less attention by the sexual function literature despite the known inhibitory effects of stress to nonfight-or-flight-related responses such as sexual arousal.

SNS.  The literature on female sexuality has found a reliable relationship between the SNS and physiologic sexual arousal [15]. Objective measures of physiologic sexual arousal such as vaginal photoplethysmography have shown greater vaginal blood flow in response to erotic stimuli after the activation of the SNS compared to states when the SNS was at rest. The opposite effect, an inhibition of blood flow in the genitals during exposure to an erotic video, was observed in women taking clonidine, which blocks SNS activity at the peripheral level. The relationship between SNS and physiologic sexual arousal appears to be curvilinear, and while a moderate activation facilitates physiologic sexual response, a high level of SNS activity has an inhibitory effect.

The relationship between SNS and physiologic sexual arousal among women with a history of CSA is particularly interesting given that the literature provides robust evidence for heightened SNS activity in these women, which may put them above and beyond the optimal level of SNS activity for sexual arousal. Indeed, compared to healthy controls, women with a history of CSA with PTSD symptoms showed heightened norepinephrine levels—one of the main neurotransmitters used by the SNS [16]. Also, urinary norepinephrine levels were higher in adult women survivors of CSA with PTSD symptoms compared to women with no history of CSA, and no different from women survivors of CSA without PTSD symptoms [17]. Additionally, heart rate and blood pressure, two indirect measures of SNS activity, were significantly higher in veterans with PTSD compared to a matched group of asymptomatic veterans [18].

Based on these results, it was hypothesized that difficulties becoming sexually aroused among CSA survivors may be partially explained by an overactive SNS, which inhibits the physiologic sexual response at the level of first-order processes. Additionally, it was hypothesized that a lack of physiologic sexual response would indirectly affect subjective sexual arousal if the individual interpreted the low physiologic sexual arousal as evidence of lack of interest in the sexual stimuli.

Partial support to these hypotheses was provided by a study of physiologic and subjective sexual arousal in women with (N = 18) and without (N = 10) a history of CSA. Compared to women with no history of sexual abuse, CSA survivors with mild to severe PTSD symptoms showed weaker physiologic sexual response to a sexual video [19]. During the second day of the study, an increase in SNS was induced through acute aerobic exercise. During this experimental condition, all women increased their heart rate by running on a treadmill for 20 minutes at 70% of their maximum volume of oxygen uptake. In agreement with previous studies, this condition was associated with increased physiologic sexual arousal in women with no history of CSA. In support of our hypothesis, the exercise condition did not increase genital vasocongestion in women with a history of CSA. This finding provides further evidence that, at the level of first-order processes, physiologic sexual arousal in CSA survivors may be negatively affected by a baseline state of heightened SNS activity, which puts these women above and beyond the optimal level of SNS activity that facilitates sexual arousal.

Differently from what was expected, women with and without a history of CSA did not show differences in their levels of subjective sexual arousal in response to sexual stimuli during the state of rest or during the SNS activation manipulation. This suggests that first-order processes implicated with the subjective sexual response were not inhibited by the activation of the SNS during the experimental session. Taken together, these results provide evidence for a first-order physiologic response that inhibits physiologic sexual arousal, but not subjective sexual arousal. This inhibition can explain problems with hyposexuality but not hypersexuality in CSA survivors.

Stress Response: HPA Axis.  The literature on trauma biology indicates impairments in the stress response (i.e., the HPA axis) in individuals with PTSD. The stress response, a key component in animal and human behavior, prepares the body to react in a fight-or-flight situation. This response is quick and can be compared to first-order processes as illustrated in the sexual response model. A cascade of neurotransmitters and hormones is activated during exposure to a stimulus that the amygdala identifies as a stressor. This cascade results in the adrenal cortex releasing cortisol, which increases the resources available in the body (oxygen and glucose) and also has the role of providing negative feedback to shut of the stress response system.

In women with a history of CSA reporting PTSD symptoms, the HPA system is impaired. A number of studies have indicated a low level of cortisol as indication of this impairment. Chronic anxiety can cause chronic elevations in cortisol, which can lead to an exaggerated stress response to stressors (e.g., loud noises) and a longer period of time to return to homeostasis [20]. Given that the traumatic experiences of CSA survivors involved sexual stimuli, it is feasible that these women experience an automatic (first order) fear response to benign sexual stimuli, which, theoretically, can inhibit the physiologic sexual response given that blood and other supplies are moved to organs necessary for fight-or-flight and not for mating.

To investigate the relationship between the stress response and the sexual response, we assessed cortisol levels before and after exposure to sexual videos in women with and without a history of CSA [21]. Contrary to our hypotheses, on average, all women in the CSA group showed a decrease in cortisol after exposure to the sexual videos. However, a subgroup of CSA survivors showed a significant increase in cortisol, indicating the activation of the stress response. It follows that the weak physiologic sexual response observed in CSA survivors compared to women with no history of abuse can possibly be a product of this automatic fear response to sexual stimuli (first-order processes).

Women showing an increase in cortisol also reported dissociating during sexual activities with their partners. Dissociation is most often understood as the product of first-order processing because it lies outside the woman's voluntary control. Indeed, the definition of dissociation is a loss of sensation and control of bodily movements. Women can learn to control their dissociative states but this requires training and an increased awareness of triggers that activate this automatic response [22]. Self-reported levels of negative affect, positive affect, and mental sexual arousal did not differ between women who did and did not show an increase in cortisol, indicating that second-order cognitive and affective responses did not associate the sexual stimuli with fear. These results provide evidence that some CSA survivors experience inhibition of the physiologic sexual response in first- but not second-order responses. These results also indicate that some women with a history of CSA experience an excitation of the physiologic stress response to sexual stimuli that can have an inhibitory effect on the physiologic sexual response.

Interestingly, dissociation is often conceptualized as an avoidance behavior because it is a way for the individual not to be present when something is upsetting. The fact that some CSA survivors, but not all, showed an activation of the stress response, which was associated with dissociation, may be helpful for understanding the distinction between hyper- and hyposexuality in CSA survivors. Based on this information, it is possible that when CSA survivors experience an activation of the stress response, they try to suppress it through avoidance of the stimuli via alteration of awareness, which results in hyposexual problems. Dissociation is activated in situations where the woman cannot (or does not want to) physically remove herself from the situation. Given the opportunity, this woman may be able to avoid this experience by preventing any type of sexual activity and therefore, reinforcing the hyposexual manifestation of her sexual problems. Further longitudinal studies on HPA activities in CSA survivors in situations of hypo- and hypersexuality are necessary to investigate whether this system is implicated in the different sexual problems common among CSA survivors.

Cognitive/Affective Responses

First-order cognitive and affective responses are complicated to identify because of the interaction between cognition and affect and between first- and second-order processes. One way to isolate the product of first-order processes is to focus on responses that are activated during the first milliseconds postexposure to sexual stimuli. A methodology that uses this paradigm is the implicit association test (IAT [23]), a test designed to compare the strength of positive and negative valence (i.e., pleasant vs. unpleasant) between two dichotomous constructs (i.e., sexual vs. nonsexual/neutral behaviors). In this test, stimuli (pictures and words) that represent two dichotomous constructs (e.g., two people having sex vs. a woman walking her dog) and the two opposite valences (e.g., joy vs. sick) are shown one at a time, on a computer screen. The participants are provided with two categories: one for sex and pleasant stimuli and one for neutral and unpleasant stimuli. Each category is located to either the right or the left of the computer monitor. The task is to quickly assign the stimulus appearing in the middle of the screen to the correct category by pressing one of two keys. After this task is repeated 40 times, the paired constructs in the two categories are switched and sex is placed in the category with unpleasant while neutral is in the category with pleasant. The assumption underlying this test is that, when the individual's implicit memories pair sex with pleasant rather than with unpleasant, the response rate is faster in the condition with the category sex/pleasant compared to sex/unpleasant.

A sample of 56 women [24] with and without a history of CSA completed two IATs to measure the association of pleasant/unpleasant with sexual/neutral (IAT 1) and with sexual/romantic (IAT 2). In IAT 1, women with no history of CSA showed a stronger sex/pleasant association compared to the neutral/pleasant association. For these women, the construct of sex was more pleasant than daily life activities such as talking on the phone, cooking, walking a dog, etc. There was no evidence for a preference of the sex/pleasant association for CSA survivors. However, sex was not more strongly associated with unpleasant valence compared to daily activities. These results suggest that, for CSA survivors, sexual stimuli were as closely associated with pleasure as daily activities such as walking a dog or answering a phone, thus indicating a lack of excitatory first-order cognitive and affective responses to sexual stimuli.

One limitation of the IAT is its close relationship with cognitive flexibility. Participants with greater mental flexibility may be better able to switch the associations between two different constructs than individuals with less mental flexibility. A history of sexual abuse can be associated with a deprived environment that can lead to lower intelligence quotient (IQ) and lower mental flexibility. We addressed this limitation by counterbalancing the conditions so that half of the participants first completed the sex/pleasant condition and the other half first completed the sex/unpleasant condition. A second limitation is that the IAT compares two constructs, which, in this case, are sex and nonsexual daily activities; thus, all the results are relative to the two constructs picked. Because of the relativity of the test, it is feasible that CSA survivors may experience a general apathy not specific to sexuality.

To gain a greater understanding of the implicit sexual memories of CSA survivors, we used IAT 2 to study the association between pleasant/unpleasant valences with sexual/romantic constructs. Both women with and without a history of CSA showed a stronger pairing between the romantic/pleasant pair compared to sex/pleasant pair. This indicates that CSA survivors, during first-order processes, are capable of showing a preference for romantic constructs compared to sexual constructs, and therefore, the lack of preference for sex compared to neutral activities, as found earlier, is likely to be derived from a lack of positive implicit sex memories rather than general apathy. To ensure that these results are not the product of habituation to the sexual stimuli used in IAT 1 and IAT 2, half of the women first completed the IAT 1 and the other half first completed the IAT 2. As lack of association between sex/pleasure may lead to low production of affective responses that excite sexual arousal, it is feasible that the weak sex/pleasure association may be a mechanism behind the hyposexual problems of CSA survivors. This is in agreement with past studies that found an association between low positive affect and sexual arousal [25].

Interestingly, on average, CSA women were slower at completing the task in both IAT tests. As in all IAT conditions participants saw sexually explicit pictures, it is feasible that the sexual stimuli activated sexual memories that distracted participants from the task, thus suggesting a potential inhibition of sexual responses caused by a distracting effect of sexual memories that the individual with a history of CSA needs to inhibit. In summary, these studies provide initial evidence for the inhibition of physiologic, cognitive, and affective responses produced by first-order processes in women with a history of CSA. Specifically, during the first-order processes, women with a history of CSA show inhibition of physiologic responses potentially caused by an overactive SNS. Some CSA survivors also experience the automatic activation of the HPA axis, which works against physiologic sexual arousal. At the cognitive/affective level, CSA survivors showed a weak association between sex and pleasure. Interestingly, sex was not more strongly associated with negative affect.

Second-Order Processes

Cognitive/Affective Responses

As indicated in the proposed model, sexual memories influence explicit cognitive processes (second order), such as sexual self-schemas, sexual fantasies, sexual likes and dislikes, and sexual scripts. Sexual self-schemas are blueprints of how people make sense of the sexual self and provide them with a map to understand their responses to sexual stimuli. While sexual schemas belong mostly to first-order processes because they are implicit and nonvolitional, schemas are also partially conscious and can be shaped by explicit memories derived from second-order processes. Indeed, a number of psychotherapies have focused on the reconstruction of schemas through the use of volitional, conscious, secondary processes [26].

Two studies used methodologies derived from social psychology to increase our understanding of how women with a history of CSA see their sexual selves and how these views impact sexual responses. In these studies, sexual self-schemas were assessed with both direct and indirect measures [27,28]. Direct methods, such as self-reported questionnaires on sexual schemas (Sexual Self-Schema Scale [29]) and sexual beliefs, were used in a sample of women with (N = 34) and without (N = 22) a history of CSA. The romantic/passionate sexual self-schema mediated the relationship between CSA and negative affect during sexual activities with a partner [28]. The other schemas assessed (i.e., open/direct and embarrassment/conservatism) were not associated with the sexual function of CSA survivors. These results were independent from symptoms of depression and anxiety, providing evidence that depression and anxiety are not necessary for the development of sexual problems in CSA survivors.

It is possible that, in CSA survivors, sexuality is not associated with passion and romance and therefore the motivation for engaging in sexual activities may be dependent on schemas not identified by the questionnaires used. Indeed, we know from studies on men and women that there are numerous reasons why people engage in sexual activities other than pleasure, such as emotional closeness, social status, stress reduction, expression of emotions, etc. [30]. An investigation of motivations for sex may reveal interesting information about differences between the sexual views of women with and without a history of CSA.

Another limitation of these results is that the questionnaires required individuals to provide a general rating of their views of their sexual selves. Thus, a woman who conceives herself passionate with strangers but not with her partner would score similarly to a woman who feels mildly passionate with strangers and with her partner. Also, it is likely that sexual self-schemas that explain the hypo- and the hypersexuality of CSA survivors may not be captured by the three schemas measured in the questionnaire used. For example, the literature has pointed out that CSA survivors often report feeling like “damaged goods” or “dented” by the sexual abuse.

A main limitation of the methodology of this study is the impact of demand characteristics on the participants’ responses. It is possible that CSA survivors may have tried to appear more sexually open and comfortable than they really are, or they may have tried to appear more troubled by their sexual problems. To address this limitation, a second study on the cognitive responses associated with explicit sexual self-schemas was performed using indirect measures of women's views of sexuality and of the sexual self [28]. Indirect measures are considered more robust to demand characteristics because participants do not know what the experimenters are measuring. The indirect measure adopted in this study was the computerized analysis of language participants used in sexually relevant text entries (Linguistic Inquiry Word Count [LIWC][31]). Social psychologists repeatedly found a significant association of word choice with personality characteristics and psychopathology [32]. LIWC is a software program that counts words falling into preestablished, reliable, linguistic categories created by expert raters. Some examples of categories featured in LIWC include food, sex, body, first person pronouns, communication, and positive emotions.

This method was considered complementary to self-administered questionnaires because questionnaires are more strongly affected by demand characteristics than linguistic analyses. When women write about a suggested topic, it is likely that demand characteristics play a role in the content of their writing, but it is less likely to affect the words they select. For example, when women describe an emotion, they can choose to write “I do not like him” or “I dislike him.” The concepts described by these two sentences are similar but the word selection is different. Social psychology studies found that the word selection is linked to personality characteristics and cognitive styles more than the content. Words chosen during communication are assumed to be the product of words belonging to the cognitive networks most commonly used by that individual. For example, depressed individuals with suicidal thoughts are more likely to ruminate on their problems and for this reason show higher rates of first person pronouns [33]. Similarly, optimistic individuals asked to describe a sad event tend to use words such as “not happy,” rather than “gloomy” because the word “happy” is part of cognitive networks more commonly used and therefore more readily available. This concept can be extended to areas other than emotions. Based on previous studies, we investigated rates of words indicating “positive affect,”“negative affect,”“sex,” and “body” in texts written on three topics: (i) a story in response to an ambiguous picture suggesting sexual topics; (ii) a sexually explicit topic; and (iii) a nonsexual topic.

Women with (N = 27) and without (N = 22) a history of CSA wrote a story in response to an ambiguous picture depicting a woman sitting on a bed looking outside a window while a man, approaching her from behind, is reaching for her hair. This picture has reliably pulled for sexual stories when used in our sexuality laboratory, thus we expected this to be a relatively ambiguous way to stimulate sexually relevant language in the participants. In the stories written by CSA survivors, LIWC counted less “sex” words compared to stories written by women in the comparison group. This result could indicate suppression of sexual thoughts in CSA survivors. It is unclear whether this suppression would occur during first- (implicit sexual memories) or second-order processes (explicit sexual memories). An inhibition of first-order cognitive responses would result in distraction from the sexually related stimuli, which would prevent second-order processes. However, it is also feasible that first-order processes are intact while volitional cognitive processes push sexual thoughts away. Indeed, trauma survivors with PTSD symptoms often push away trauma-related thoughts or memories.

The linguistic analysis revealed that women with a history of CSA used significantly more “negative affect” words when writing about the ambiguous picture. Words like “in love” and “tender and sweet” were more common in the stories written by the comparison group. Words like “fight,”“feeling trapped,”“prisoner,”“being forced,” and “sad” were more common in the essays written by the CSA group. The CSA group also used less “body” words compared to women with no history of CSA. More “negative affect” words and less “body” words were positively correlated with low sexual desire, suggesting that hyposexual problems in CSA survivors are associated with the inhibition of thoughts related to “body” and the excitation of “negative affect.”

In the sexually explicit essay, women wrote about their sexual fantasies. This topic was selected to examine the words chosen when participants explicitly focused on positive aspects of sexuality. We were interested in whether the explicit recall of positive sexual thoughts could override the responses associated with negative implicit sexual memories. Indeed, the percentage of negative affect words in the essays written by CSA survivors did not significantly differ from those written by the comparison group, suggesting that women were able to inhibit negative sexual memories that may have otherwise emerged. However, CSA survivors used less positive affect words. This result parallels what we observed in the IAT study in that sex was not necessarily associated with negative valence but was not strongly associated with positive valence. A potential clinical implication of these results is the importance for CSA survivors with sexual problems to develop positive implicit and explicit sexual memories.

In the nonsexual essay, women wrote about their previous day. This neutral topic was used for comparison with the other essays to ensure that the patterns previously noticed were specific to sexual thoughts. Indeed, no differences were observed in “negative affect,”“positive affect,” or “body” words. Interestingly, CSA survivors used more “sex” words in the nonsexual essay than the comparison group. This result may be the product of cognitive associations that link uncommon stimuli to sex.

In summary, the affective and cognitive responses active during second-order processes differ between women with and without a history of CSA. Those CSA survivors who experience themselves as not passionate or romantic report negative affect during sexual activities with their partners. Also, stimuli that most people associated with sex constructs activated negative affect in CSA survivors. When describing positive sexual thoughts, CSA survivors used significantly less positive affect words than the comparison group. Finally, nonsexual stimuli stimulated more sexual thoughts in CSA survivors than the comparison group.

Conclusions

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

The fields of sexual function and sexual abuse would benefit from studies investigating the mechanisms that pertain to the sexual problems of CSA survivors. In an attempt to inform future studies on this topic, a theoretical model was developed from two preexisting models of sexual response: the IPM and the DCM. The combination of these two models allows for a greater understanding of the problems in CSA survivors. In particular, this model integrates physiologic, cognitive, and affective responses typical in sexual arousal. Another advantage of this model over previously proposed ones is the consideration of the co-occurrence of hypo- and hypersexuality in the same individual.

A series of studies have been presented in support of the model's effectiveness in explaining the hypo- and hypersexual problems of CSA survivors. In these studies, potential mechanisms of hyposexual problems were observed in physiologic, affective, and cognitive responses. These results point to a greater production of inhibitory responses and the reduction of excitatory responses in CSA survivors compared to women with no history of CSA. Specifically, physiologic processes with a known excitatory effect on sexual arousal, such as SNS, did not facilitate sexual arousal in CSA survivors. Also, systems with inhibitory effects on physiologic sexual arousal, such as the HPA axis, were active in a subset of CSA survivors during exposure to sexual stimuli. Moreover, first- and second-order processes showed a lack of excitatory affective responses. For example, sex was not paired with pleasure and sexual fantasies were described with less positive affect in the essays of CSA survivors. CSA survivors also showed a greater use of negative affect when describing stimuli commonly associated with sex. Finally, stimuli expected to activate cognitive sexual responses, such as the ambiguous picture used in the linguistic analyses, failed to activate cognitive associations with sex in CSA survivors.

The literature provides a compelling body of evidence regarding the hypothesized effects of physiologic, affective, and cognitive responses on the hyposexual problems of CSA survivors. For example, the effect of physiologic responses on hyposexual problems is supported by two studies comparing physiologic sexual arousal in women with and without a history of CSA [34,35]. In both studies, the physiologic sexual response was significantly weaker in CSA survivors than in the comparison groups. The association between negative affective responses and sexual constructs has been documented in a study on cognitive networks [36]. In this study, CSA survivors paired words about genitals with negative affect. Second-order affective responses and sexual schemas were found impaired in a study of women with pelvic pain [37]. This study found that CSA survivors had significantly less positive sexual self-schemas compared to women with no history of sexual abuse, corroborating potential inhibitory (or lack of excitatory) cognitive and affective sexual responses. Finally, research that investigated the emotional response of CSA survivors during sexual activities indicated the presence of shame and negative affect during sexual arousal (e.g., [38]).

Evidence for mechanisms involved in hypersexuality in CSA survivors was mostly observed in first- and second-order cognitive responses. Stimuli not commonly associated with sex (i.e., the description of the previous day) showed a greater activation of sexual cognitive responses in CSA survivors compared to women with no history of CSA. Additionally, slower response rates were observed among CSA survivors in all IATs compared to women with no history of CSA. The slower response rate could indicate the presence of nontask-related thoughts and the inability of CSA survivors to inhibit these thoughts. As the two IATs were counterbalanced and sex was the only construct present in both IATs, it is feasible that the memories that CSA survivors could not inhibit had to do with sexual memories. Indeed, inhibiting intrusive thoughts is not uncommon for CSA survivors who experience PTSD symptoms.

Taken as a whole, these results suggest that the excitation of sexual stimuli lacks predictability and CSA survivors lack the control to inhibit these responses. Brain imaging studies have also shown that CSA survivors have difficulties inhibiting thoughts and behaviors. For example, in studies on borderline personality disorder, a population with high rates of CSA and hypersexuality, patients had impairments in the orbitofrontal cortex, an area responsible for the inhibition of thoughts and behaviors [39]. Further evidence for impairment in inhibitory processes was presented in a sexual psychophysiology study on women with and without a history of CSA [34]. The participants were asked to inhibit or enhance their physiologic sexual response to sexual stimuli in the laboratory. In this study, CSA survivors showed the same amount of physiologic sexual arousal whether they tried to maximize or minimize their physiologic sexual arousal. The combination of intrusive sexual responses and the inability to suppress these responses may indeed explain problems with overpreoccupation with sex and the tendency to engage in sexual activities to cope with these thoughts.

This view of hypersexuality resembles to the traumatogenic sexualization model proposed by Finkelhor and Browne [40]. According to their model, CSA survivors learned inappropriate or dysfunctional associations with sex. The model proposed here also emphasizes the importance of learned implicit and explicit cognitive associations. The results from the studies reviewed support the activation of cognitive associations at times when sexual responses are not expected. At this point, it remains unclear what excites these cognitive sexual responses. Future research that explores nonsexual stimuli that activate physiologic and cognitive sexual responses may bring a greater understanding of hypersexuality.

Overall, the main clinical implication of these results is the need to include interventions that help clients to develop stronger associations between sex and positive affect. It is critical that these interventions address implicit and explicit responses differently. As some observed that first-order responses were inhibitory—a reduction of these can be particularly useful for the treatment of hyposexuality. First-order automatic responses are usually more effectively addressed with behavioral techniques that teach individuals to unlearn a dysfunctional learned response. For example, exposure to stimuli that activate the inhibitory response and the introduction of an alternative excitatory response is a way to counteract this learned pattern. With regard to second-order processes, cognitive interventions are likely to be more effective at addressing impairments in these areas, particularly the use of cognitive techniques that increase expectations of positive outcomes during sexual activities. Also, helping women to rebuild a positive view of their sexual self can improve some of the impairments observed in the second-order responses. For example, an intervention specifically designed to increase comfort and positive attitudes toward the body can improve sexual desire as a negative relationship was observed between body and sex in the linguistic analyses of texts written by CSA survivors. The importance of body image in CSA survivors was also reported in studies that identified an association between negative affect and genitals [35], and by studies that found a high incidence of negative views of the body in sexual abuse survivors [41].

The body of evidence in support of this model is only in its initial stage. The results reviewed here must be replicated and confirmed by more in-depth studies that specifically target the sexual problems of CSA survivors. Further, the model needs to be validated for women that have been sexually abused in adulthood, and for male survivors of sexual abuse. Some basic information about hyposexuality and hypersexuality remain unknown. For example, the relationship between hyposexuality and hypersexuality is relatively unexplored. To date, only one study looked at this relationship and found that CSA survivors with more sexual dysfunction (hyposexuality) reported problems with hypersexuality [2]. Because of the lack of information on these sexual problems, the present model was based on the assumption that, at least for some CSA survivors, hyposexuality and hypersexuality coexist in the same individual. However, it is also possible that some CSA survivors develop only hyposexuality while others develop only hypersexuality. Future longitudinal studies on hyposexuality and hypersexuality can adequately explain the relationship and the course of these two problems in CSA survivors. Such information could open the field to potential biologic characteristics, which can inform treatments to prevent sexual problems in CSA survivors.

In conclusion, the model presented in this review has shown promising qualities. It is particularly noteworthy that empirical studies confirmed a distinction between impairments in first- and second-order processes. Such a distinction has relevant clinical implications as the optimal clinical intervention (e.g., cognitive vs. behavioral) could be identified more readily with these processes. Additionally, the differentiation of the cognitive, physiologic, and affective responses in this model allows the identification of impairments in specific areas that can then be targeted in therapy. Thus, the available evidence calls for treatments of hypersexuality to focus on cognitive responses. Clinical studies for the treatment of hypo- and hypersexuality of CSA survivors are now warranted. While it is challenging to develop and test a sex therapy intervention for a specific portion of the population such as CSA survivors, especially when the field lacks empirical evidence for more general sex therapies, it is our hope that the model proposed in this review will provide a framework to guide clinical researchers who follow this understudied area of research.

Acknowledgment

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

This publication was made possible by Grant Number F31 MH68165 from the National Institute of Mental Health to Alessandra Rellini. The contents of this manuscript are solely the responsibility of the author and do not necessarily represent the official views of the National Institute of Mental Health.

Conflict of Interest: None declared.

Statement of Authorship

  1. Top of page
  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References

Category 1

  • (a)
    Conception and Design
    • Alessandra Rellini

  • (b)
    Acquisition of Data
    • Alessandra Rellini

  • (c)
    Analysis and Interpretation of Data
    • Alessandra Rellini

Category 2

  • (a)
    Drafting the Article
    • Alessandra Rellini

  • (b)
    Revising It for Intellectual Content
    • Alessandra Rellini

Category 3

  • (a)
    Final Approval of the Completed Article
    • Alessandra Rellini

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  2. ABSTRACT
  3. The Sexuality of CSA Survivors
  4. Looking for a Homogenous Group of CSA Survivors
  5. A Theoretical Model to Understand Sexual Dysfunction in CSA Survivors
  6. Empirical Studies
  7. Conclusions
  8. Acknowledgment
  9. Statement of Authorship
  10. References
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