Adult Survivors of Childhood Sexual Abuse in South Asia: Impact and Interventions for Trauma Recovery

Childhood Sexual Abuse (CSA) can have persistent effects which could continue into the adult lives of survivors. Given its repetitive nature, CSA is classified as a form of complex trauma. It puts the adult survivors at risk of developing Complex-Post Traumatic Stress Disorder (C-PTSD). South Asia has reported high rates of CSA cases. The region including Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka is the most populated region worldwide, with 2.5 children per woman. Except for Afghanistan, which does not have a reliable source of knowing CSA prevalence rates, the remaining countries have reported increasing rates of abuse against children. 

With elevated rates, it is important to understand the experiences and efficient intervention strategies for supporting the recovery of CSA survivors. There exists a stark cultural difference between South Asian and Western countries. As South Asians live in a collectivist culture, Western treatment strategies focusing solely on the individual might not be helpful in this context. Hence, to understand the impact of CSA as well as the treatment offered to them, Shivangi Talwar and colleagues conducted a review of existing research studies. They also checked whether the treatment offered led to desired outcomes (termed efficacy) and whether the treatment recipients found it appropriate to their needs (termed acceptability). 

Their review focused on published research about the impact and treatment of CSA from all 8 South Asian countries. However, in their study, they found that relevant research was only available from 4 countries, including India, Nepal, Pakistan, and Sri Lanka. A total of 24 existing studies were included in the review. Of these 24 studies, only one was published in 1992, and the remaining were published between 2009 and 2022. 

Impact of CSA 

Of the 24 studies included in the review, 20 discussed the impact of CSA on survivors. The impact is presented in the following four categories: 

Mental Health Conditions 

Multiple emotional difficulties like dissociation, difficulty in verbalizing emotions, feelings of anxiety, feelings of insecurity, fear of revictimization, as well as depressive symptoms like low mood, low self-esteem, irritability, were reported across 12 different studies. 

Interestingly, two studies reported contradictory findings. One mentioned that traumatic experiences in adulthood, rather than childhood, led to emotional difficulties. The other found no emotional regulation problems in people with CSA histories.

Apart from emotional difficulties, recurrent suicidal and self-harming behaviour was noted as one of the main mental health difficulties among CSA survivors. Only five studies conducted in India and Nepal studied the risk to self and reported this finding. 

Many cognitive and behavioural difficulties were also reported across six studies conducted in India and Nepal. The cognitive difficulties included self-blame, obsessive thoughts of contamination, fantasies of violent sexual behaviour, and difficulty in concentration. The behavioural difficulties included reckless and impulsive behaviours, avoiding males and public places, and rude behaviour with elders. One study also reported disturbances in identity and paranoid ideas in CSA survivors. No specific psychotic symptoms were reported. 

Four studies also reported physiological difficulties like nightmares, leading to sleep difficulties. Sexual difficulties were also noted, such as an inability to restrain physical intimacy and decreased interest in sexual activities. Somatic complaints included tenderness in the lower abdomen, headaches, and weakness. 

Impact of CSA on Interpersonal Relationships

Seven studies reported the impact of CSA on interpersonal dynamics. Some of the difficulties include forming and maintaining intimate relationships as well as the inability to confide in one sexual partner. Adult male survivors in a Sri Lankan study were found to be twice as likely to perpetrate sexual intimate partner violence. In another study, male survivors reported questioning their sexual orientation when abused by same-sex perpetrators. Two Indian studies did not report any association between relationship difficulties and CSA experiences. 

Society’s Response to the Disclosure of CSA 

Five studies in the review, all conducted in India, showed families’ and others’ unsupportive responses to the disclosures of abuse by survivors. Such responses include silence, dismissal, poor emotional support by family members, the family’s effort to conceal the abuse, forceful marriage with the perpetrator, being blamed for attracting attention, and being labelled as a “loose woman.” Given such responses, the authors noted the barriers to disclosure. They mentioned, 

“Barriers to the disclosure of abuse included fear of negative consequences, feelings of guilt, fear one will not be believed by their family, loyalty to the perpetrator (Rathinam, Singh, Chopra et al., 2021; Rathinam, Singh, Gupta et al., 2021), the expectation to maintain their secret pact with the perpetrator(s), believing that it was something they enjoyed, feeling ashamed of the sexual nature of the event(s), protecting the perpetrator’s reputation, and protecting others from getting upset (Sharma, 2022a).”

It is interesting to note that two studies conducted three decades apart – one in 1992 and the other in 2022 showed similar societal responses to the disclosure of CSA. 

CSA Experience and Offending Behaviour 

More adverse childhood experiences (ACEs) were reported in cases of offenders as compared to non-offenders. However, one study reported the frequency of CSA to be the least prevalent ACE among violent offenders.

Treatment Offered to Survivors 

Only six studies among the 24 discussed the treatment and recovery of CSA survivors. None of the studies reported the efficacy and acceptability of the treatment offered. The various treatment strategies have been categorized below.

Psychological Treatments

Cognitive behavioural therapy (CBT) was the preferred choice of treatment by clinicians. In some cases, the treatments were offered in groups and were trauma-focused. The authors identified the goal of psychological treatment and mentioned, 

“The goals of psychological treatments involved “maintaining self-control and libido” (Mujawar et al., 2021), envisioning a hopeful future, supporting their religious beliefs, protecting them from perpetrators’ threats (Guragain & Ghimire, 2017), and improving self-esteem, decision-making abilities, and emotional difficulties (Grover, 2005, 2008).”

Pharmacological Treatment

A single study conducted on a single individual, an Indian female CSA survivor, reported pharmacological treatment. The CSA survivor showed sexually disinhibited behaviour and was prescribed fluoxetine. The authors noted the limited generalizations from this particular study.

Recovery and Healing 

Two qualitative studies based on the interviews of survivors noted their recovery process. 

Both studies highlighted that CSA survivors may not seek professional help and find their own ways of processing and meaning-making of their CSA experiences.

One study on a nonclinical sample of 20 survivors from India put forward a recovery framework. Here, the recovery was described in four phases, including turmoil and confusion about sexual abuse, awareness or symbolization of abuse happening to them, activating their recovering self, and, finally, reaching a stage of self-reconnection and reintegration. 

Need for Validated Treatment for South Asian CSA Survivors

In discussing the findings of their review, the authors mention some significant differences in the context of CSA from Western countries like the UK, the USA, and Australia. Some of these differences in the impact of CSA include no reporting of experiential avoidance or internal reminders, flashbacks, PTSD, and eating disorders. To clarify, experiential avoidance is the tendency to avoid sensations, thoughts, feelings, and other internal experiences that might be unpleasant and painful for the person to remember and recall. 

In Western Countries, Eye Movement Desensitization and Reprocessing (EMDR) is the preferred mode of treatment. However, South Asian studies did not report such a preference.

Given the differences in the impact of CSA on survivors as well as the cultural differences between South Asian and Western regions, there is an urgent need to build validated treatment and intervention strategies for CSA survivors in South Asia. 

The review has clearly established the gap in culturally validated treatments. Therefore, it asks an important question: What are mental health professionals currently doing for the treatment of people affected by trauma, especially the case of CSA survivors? To answer this question, Shivangi Talwar and colleagues conducted another study where they recruited mental health professionals and other key stakeholders in South Asia to learn about current treatment practices. They considered it important not to look at CSA in isolation because “in a South Asian context, many professionals are working with survivors experiencing financial, military, disasters, and political-related complications.”

Views of Mental Health Professionals and Other Key Stakeholders to Understand Current Treatment Practices

In their second study, Talwar and colleagues interviewed 17 professionals working in South Asia of which two were stakeholders (an organisation lead and a programme manager) working with CSA survivors in India and remaining 15 were mental health professionals including six from India, one from Afghanistan and two each from Pakistan, Nepal, Sri Lanka and Bangladesh. Despite efforts to recruit participants from the Maldives and Bhutan, they did not receive responses from the professionals contacted. The themes from the interviews with these professionals have been categorised as follows:

Mental Health Symptoms as the Tip of the Iceberg

The professionals mentioned that as mental health symptoms are visible on the surface, they are often reported. However, underlying such symptoms lies trauma.

Their clients did not link their current mental health difficulties with recent or past traumas.

Clients with traumatic experiences presented difficulties with interpersonal relationships as well as common and severe mental health disorders. 

Additionally, all mental health professionals, especially psychologists, mentioned that their adult CSA survivor clients consult them at the suggestion of other medical professionals. An Indian clinical psychologist mentioned, 

“……who have been told by their psychiatrist that…looks like in your history, this is because also of something that you have gone through in the past. So you should consult a psychologist….they come to me asking question that do you think that has links to the problem that I am experiencing now because my psychiatrist says that now I should see you….but they do not exactly understand why we are doing this, why we have to talk about something which is gone in the past.”

The participants also shared that survivors usually avoid discussing their developmental sexual trauma. It is only after a few sessions that they disclosed their experiences, with or without realizing that their current symptoms might be related to such trauma. A Pakistani Academic and Clinical Psychologist shared, 

“……when we take their histories and go in depth…. after a few sessions and depending on our questions and how resistant the client is…. if the client is comfortable by then and…. does not feel threatened….so we avoid asking such questions in initial sessions….”

It was also seen that clients did consider CSA as abusive; however, other forms of childhood abusive experiences, like physical abuse and neglect, were not considered traumatic.

An Indian clinical psychologist shared:

“…… here, physical abuse is as common as boxes of sweets. They don’t want to consider physical abuse as abuse. It’s considered as a part of parenting, and I openly say that abuse is happening in the name of parenting……”

Some professionals did not directly ask their clients about experiencing trauma, like CSA. They considered the processing of trauma memories as the main goals of treatment. Other professionals, however, considered the processing of trauma memories as unpleasant and thus avoided it. 

Pragmatic approach to treatment and services

The professionals highlighted that they responded with a pragmatic approach to the diverse needs of their clients and the availability of limited resources. For instance, clients demanded quick fixes by requesting medications and immediate support instead of long-term engagement for processing trauma memories. 

Most professionals also recognised the gap between published evidence and the presenting concerns of their clients with trauma. They mentioned that they adapt Western treatment strategies as per the education level, region, and mental health literacy of the survivors to support their clients. However, they faced challenges in further tailoring the treatment. A Nepalese Academic and Clinical Psychologist shared, 

“I think we when we try to imitate or try to practice the way they (in the West) are, I think sometimes the things do not fit at that time (in our country).”

Additionally, most participants mentioned that a diverse team of professionals is required to provide services to trauma survivors. A psychiatrist noted that although they can prescribe similar medications to all their patients, it is only a psychologist who can plan the treatment according to the client’s difficulties. 

Moreover, professionals in the study shared that they use a diverse range of treatment modalities for trauma survivors, like EMDR, Acceptance and Commitment Therapy (ACT), Dialectical Behaviour Therapy (DBT), psychodynamic approaches, and trauma-focused CBT. Some professionals preferred CBT the most among all approaches. 

Further, given the collectivist culture, all professionals highlighted the importance of family in treatment. A stakeholder from India shared, 

“When nobody in the family knows that you have been abused by this person. But being expected to be part of family functions and to be part of, you know, and retain your sanity, for example is very much very Indian, South Asian…whether you are living with them, you are never away from them in a way…but relationship with the abuser…like your father’s 4^th cousin is also a family member…”

Systemic factors are often roadblocks to trauma services

All professionals echoed the lack of availability of resources to meet the needs of trauma survivors. They also mentioned feeling overburdened with the increasing number of clients presenting with traumatic histories. The professionals also talked about the lack of funding for researching the experiences of trauma-affected people. A stakeholder from India shared, 

“We just don’t have people who are willing to do research with us and get us some money to do it. So it’s always part of our wish as a way of putting out work.”

Some mental health professionals also discussed the lack of training facilities in their countries, as well as the smaller number of training institutes and the number of intakes. Such a lack of training leaves them unequipped to deal with clients experiencing trauma. Additionally, professionals also expressed their disappointment in the lack of regulatory bodies. A Sri Lankan Academic and Clinical Psychologist shared, 

“in Sri Lanka is that we don’t yet have an established Sri Lanka psychological association. It’s sort of unofficial, it’s not yet recognized from the parliament as a statutory body, so there’s no way of controlling the fear of…so called therapists or counsellors and you know, education and qualifications…”

Further, the professionals mentioned that due to the lack of supportive services for them, it might be difficult for them to continue providing services as they are constantly exposed to vicarious trauma. An Indian Clinical Psychologist shared, 

“I do feel that mental health professionals working with vulnerable population, they do require, some support in that way, but especially those working with trauma… one of my close friend….tells me about the numbness that she feels….an emotional responsiveness to situation has reduced because she has heard so much…. “

Many professionals also expressed the understanding that many of their clients cannot afford to pay for long-term treatment and support. They also recognized that the political climate of their countries further impacts the nature of trauma experienced by their clients. 

Cultural beliefs and practices across communities

The participants reported that working with trauma survivors, especially CSA survivors, was impacted by cultural backgrounds, religious beliefs, and community practices.

For instance, they mentioned that CSA survivors may make sense of their traumatic experiences as per the cultural norms and mental as well as sexual health literacy.

Such personalised understanding stops them from seeking professional help. 

Additionally, unlike non-South Asian published evidence, the professionals involved family members in treatment, and, in the case of CSA survivors, provided sexual health information in psychoeducation. A Pakistani professional further shared that survivors may be silenced from disclosure as abuse breaches the religious codes, especially in the case of same-sex perpetrators. They shared, 

“This is crime if we talk about Islam to have male-to-male relationship plus extramarital affair, be it bisexual…. client considered it a huge crime…”

Some clinicians also mentioned how faith healing is preferred in their countries. Other clinicians pointed towards the alignment of treatment modalities with religious practices. 

Concluding notes

The views of mental health professionals suggest that there is a need to increase awareness about mental and sexual health in a culturally appropriate manner in the South Asian region. However, despite the lack of knowledge and training, mental health professionals tend to take pragmatic approaches to work with their clients. Additionally, they recognize the systemic barriers like financial disadvantages and political unrest that further affect people’s mental health and stop them from seeking professional help. 

With constant silencing due to various reasons, the impact and extent of abuse take a while to be recognized and disclosed in treatment. Additionally, the lack of evidence on effective treatments for people affected by trauma, especially CSA survivors, needs urgent attention. It might be helpful to refine non-South Asian treatment strategies and validate their efficacy and acceptability on the South Asian population as per the cultural fit. 

Researcher Contact Info: Shivangi Talwar [[email protected]] 

Research Article Citation: 

1. Talwar, S., Osorio, C., Sagar, R., Appleton, R., & Billings, J. (2024). What are the Experiences of and Interventions for Adult Survivors of Childhood Sexual Abuse in South Asia? A Systematic Review and Narrative Synthesis. Trauma, Violence, & Abuse, 25(4), 2957-2971.
2. Talwar, S., Stefanidou, T., Kennerley, H., Killaspy, H., Sagar, R., Appleton, R., & Billings, J. (2024). Mental health professionals and key stakeholder views on the treatment and support needs of trauma and adult survivors of childhood sexual abuse in South Asia. PLOS Mental Health, 1(4), e0000136.

Links to Study: 

1. https://journals.sagepub.com/doi/full/10.1177/15248380241231603
2. https://journals.plos.org/mentalhealth/article?id=10.1371/journal.pmen.0000136