This is another of those topics I really wish I didn’t have to do. In this interview with Dr. Jennie Noll of Pennsylvania State University, we discuss the impacts that sexual abuse can have on a child (even many years after the event itself!), and we talk extensively about what parents can do to prevent abuse from happening in the first place. If you want to be sure to remember this info, there’s a FREE one-page cheat sheet of the 5 Key Steps Parents Can Take to Prevent Sexual Abuse available here:

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  [accordion] [accordion-item title="Click here to read the full transcript"]   Jen: 01:26 Hello and welcome to the Your Parenting Mojo podcast. We have a pretty serious topic to cover today and it's what I've been thinking about for a long time now. In 2016 the USA gymnastics sexual assault scandal broke and we learned that Dr. Larry Nassar had been sexually assaulting gymnast for years as he claimed to be providing them legitimate medical treatment. Now obviously there were failings at so many levels here. This was reported and ignored and covered up at many levels. But one thing that stuck in the back of my mind was an interview with gymnast Aly Raisman where she said she really thought this was what medical treatment was like and I want to be 100% clear that I'm not blaming Raisman or any other gymnast who had this awful experience, but I just couldn't get my head around how and why she didn't know she was being sexually abused.   Jen: 02:11 I realized that it's at least partly because we live in a culture where we don't talk about this. We don't teach children to watch for warning signs and we don't look out for them ourselves as parents or we pretend we don't see them. We just stick our head in the sand. So today's episode is probably not one you want to listen to with children around because we're going to be very explicit and discussing sexual abuse and how to prevent it. I also want to give a shout out to listener Christine who helped me to think through some great questions to ask my guest today. I spent a really long time looking for someone to talk with us about this and finally found the right person. Dr. Jennie Noll is Professor of Human Development and Family Studies and Director of the Child Maltreatment Solutions Network at Penn State University.   Jen: 02:52 She earned her Ph.D. in Developmental Psychology and Statistical Methodology from the University of Southern California. The reason I’m so interested to talk with her about this topic is because she has active research projects on two topics that are very important to us, the long-term health outcomes for victims of child sexual abuse and programs for the prevention of that abuse. Welcome Dr. Noll.   Dr. Noll: 03:13 Thank you very much for the opportunity.   Jen: 03:16 So before we get started, I actually also want to mention that I took the training that Dr. Noll studies and it's called Stewards of Children and it's published by an organization called Darkness to Light. I've created a free one page guide to preventing sexual abuse that you can download from this episode's page at YourParentingMojo.com/SexualAbuse. So we're going to talk a lot more about the Stewards of Children program today I imagine. But I wonder if we can get started by looking at the mental health or the general health actually impacts of sexual abuse because I was really surprised to find out how many of these there are. Can you walk us through these and do we have any indication of how likely they are to occur in a child who is chronically abused for years versus one who experiences abuse that it's discovered or reported fairly quickly.   Dr. Noll: 03:58 Yeah, very good. So what we've understood and this has been my work for the last 30 years, what we've understood really well as sort of the mental health and emotional health consequences of abuse. We have pretty good trauma informed treatments for mental health. These are things like persisting posttraumatic stress disorder, other anxiety disorders, depression, other sorts of attachment related disorders in terms of not being able to attach to a partner, relationship difficulties, and substance abuse. These kinds of things that we normally think about as mental health or emotional health. But what we're learning I think in the last decade is something that surprised a lot of us and that is just how we see sort of physical health consequences that we didn't really anticipate when we were just studying mental and emotional health and these are things like physical health disorders, these are heart attacks, obesity, strokes, stress-related diseases like inflammation, interferences with disease processes. Dr. Noll: 05:04 These are the kinds of things that we see in chronically stressed populations like PTSD Vietnam vets, people who have endured long and chronic stressors in their lives early on. And we think about this as how does stress sort of get under the skin and impact physiology? And we're talking about not just disease process but brain development, right? Other sorts of major organs, systems, the stress response system. So after studying survivors, which I have done for over 30 years and across generations, we're really starting to see a strong causal influence of early sexual abuse on long-term health outcomes because of the early and chronic exposure to stress and the stress hormone cortisol and other assaults on the stress response system.   Jen: 05:57 Wow, that's incredible. So that completely makes sense from the sort of chronically abused perspective, if the stress is ongoing for a really long period of time. Do you see similar effects in people who have this experience maybe once or twice and it's discovered fairly quickly?   Dr. Noll: 06:13 Yeah, that's a great question. It has two parts to the answer and my answer would be it depends. It sort of depends on what outcome you're looking at. For example, when we look at things like, sexual development, promiscuity, teen pregnancy, sort of more sort of sexual outcomes, right? Those are not necessarily tied to physical health, but something to do with the severe sexual boundary violation that has happened in the context of sexual abuse. I actually have some papers that really show clearly that it doesn't matter all that much if it's happened chronically or one time or several times or at what age, but more the fact that there was a sexual boundary violation and some kind of trust that was violated early on. So I don't like to put things on a continuum from mild to severe or one time to chronic. It's more about the interpretation of that violation and how it happened and the context in which it happened that helps us understand the sequelae and how to treat this kind of survivor.   Jen: 07:20 Okay. So that leads me to think about, what's the prevalence of these kinds of problems among children who are sexually abused? We actually did an episode on Intergenerational Trauma and how that's passed down through the generations and it's amazing. Some people can experience incredible trauma and not pass it onto the next generation and the vice versa happens as well. So I'm wondering, do most children manage these transitions to adolescence and adulthood kind of okay, kind of normally as it were or are problems really common?   Dr. Noll: 07:49 I think problems are a lot more common than we initially had thought about because of our work, not just mine, but others in the field where we follow survivors through time and we're able to compare those to kids of a normal developmental trajectory. And what we see is as much more common in survivors than in the normal population. Things like I've talked about and things like sexual outcomes, depression, mental health, and also these physical health outcomes. So much more common, significantly more common than would be accounted for by chance than the general population. But you're right, the road to resilience I think is under studied and under understood. And we are trying to look at models now of those who do not have affects. Those do not seem affected and what can we learn from those trajectories. Those are things like having a really good support system early on in life, having someone who believes in you, having some good evidence based trauma treatment early on, and also revisiting these issues as different developmental transitions happen.   Dr. Noll: 08:53 For example, getting married often triggers some effects of sexual abuse as memories or sort of clarified and uncovered and even experienced differently in the context of a new relationship or a new sexual relationship. Also the birth of a child can trigger a trauma symptoms as well. So we often suggest revisiting of treatment as survivors go through their lives. These are the kinds of success stories that we hear. In terms of intergenerational transmission, let me just say one thing quickly. We don't see necessarily victims of sexual abuse going on to sexually abuse their children. That's not the kind of intergenerational transmission we're talking about. We're talking about sexual abuse victims recreating an environment for their children were adversity persists or where other people have access to their kids who might be exploitive individuals who then pass sexual abuse on to those kids or physical abuse or neglect. So what happens with a survivor when they become a parent, if they have substance abuse issues or other mental health issues, children suffer because of those kinds of issues. Not necessarily because they are being sexually abused by a person who's a survivor. So let me just make clear, it's about the environment that's recreated or abuse and neglect are allowed to persist in that environment as opposed to someone sending that perpetration per se along to their kids. Does that make sense?   Jen: 10:26 Yeah, it does. So it sort of sets up a potential problem for researchers, isn't it? If you're not necessarily in studying the next generation, but in the current person who's experienced that abuse, if they are also in an environment where physical abuse is common and neglect is sort of ongoing, how do you and how do other researchers untangled these effects of the sexual abuse compared to the other co-occurring adverse child experiences that the child might be going through?   Dr. Noll: 10:51 Yeah. Another great question and I think what we have to do is look carefully at the research that's out there and how it's designed. I am chiefly charged with doing just what you said, how do I create models and research designs that actually parse out the impact and the causal impact of sexual abuse when accounting for all of the other adversities, other types of abuse, etc. that are happening in the lives of survivors. So our models are very, very comprehensive. We monitor and model all kinds of adversities and we do what we call statistical controls for those to see if there's a variation above and beyond other adversities that can only be explained by the experience of sexual abuse. We indeed have long-term longitudinal studies that actually show the effects of sexual abuse being different. As always, it depends. It depends how you're looking at. This is particularly pronounced when we're looking at sort of sexual context outcomes like teen pregnancy, teen motherhood and sexual activities.   Jen: 11:55 Okay. So I'm wondering, are there factors that can protect children who have been sexually abused from some of these outcomes? Or is it sort of inevitable that they might happen depending obviously on the abuse and the person's individual circumstances?   Dr. Noll: 12:11 Oh, this is far from inevitable and if that's one message I could get through that.   Dr. Noll: 12:17 These kinds of problems persist when the environment doesn't change. So there's a lot of propensity toward revictimization. So that is someone who might've been a survivor of sexual abuse ends up in an abusive relationship when they get older or they're raped or they're in a domestic violence situation, etc. etc. because the basic environment never changes, right? And the basic coping mechanisms and coping skills never change. But with adequate support from caregivers, from mentors, from other strong women and men in the lives of survivors, these trajectories can change, these environments can change and as well as really good evidence based trauma treatments, right? These are all things that target exactly the mechanisms that we see complicating the lives of survivors.   Jen: 13:06 Okay. So I want to get really practical. What form does this support take? Who is this coming from? What does a parent do when their child has experienced something like this?   Dr. Noll: 13:14 Oh, the very first thing in the paramount of everything that we talk about with survival is believing the victim. This is a basic tenant of prevention as well. Being able to listen, being able to understand what abuse really is, and then being able to really listen to the survivor and make that report to the official so that it stops. Stopping it and believing, those are the important features of the road to recovery. So that's the very first thing and then continued support, right? Continued monitoring throughout development, throughout the various developmental stages that’s the survivor might accompany like say transition to puberty, transition through adolescence, transition to adulthood. These kinds of milestones often trigger trauma symptoms and there should be supports in place at every single one of those transitions so that survivors continually feel the support. It can be a parent, a sister, an aunt, a boyfriend, a husband, a caring individual who understands and that survivors can confide in, a really good therapist, a clergy member who's trusted. These are the kinds of support systems that often do show up regularly in success stories.   Jen: 14:30 Okay. So what these people are specifically doing is, I mean in the short term, believing that it happened and in the longer term providing empathy and a person to talk to. Are there specific things other than that sort of general, I'm here if you need to talk kind of thing that successful support systems exhibit?   Dr. Noll: 14:48 Just like in any support system, it's sort of holding the person accountable to their treatment. Right? Going to treatment, making sure that it happens. Having the right kind of insurance coverage, those kinds of things parents can do for their children. But also making sure they go to the sessions, making sure they adhere, going with them if need be. And also looking for other ancillary systems like substance abuse, right? Problematic relationships. If these things sort of crop up at certain periods, that might mean the coping mechanisms are breaking down and that treatment should be revisited. So just looking at the lives of survivors and just loving people through. That's what we do in a caring society.   Jen: 15:28 O kay. So I want to make a shift here because I think this is important to parents as well. Talking about the prevention of sexual abuse. So firstly, can we talk about how common it is for children to be sexually abused?   Dr. Noll: 15:40 Oh boy. It depends. I'm sorry, I keep saying depends because it's important to understand the nuances of the question if you're really going to understand how to prevent it. So there are two ways at looking at the incidents, let's say. And that is sort of what do we know about confirmed cases in the US, right? So we see about (I don't remember what the numbers are today) but we see about it is tens of thousands per year in the US where we have confirmed cases of sexual abuse that meet the criteria of substantiation in various jurisdictions. But if you look at the CDC stats and what the CDC says about the incidents of sexual abuse, they estimate that based on retrospective reports of adults looking back over their lives, that about one in 10 women will experience sexual abuse by the time they are 18 and about 1 in 5 men. So those numbers are largely, you know, there's a large discrepancy between the cases that we know about that reach protective services and the cases that adults say happened when they were children. So somewhere in between is my guess.   Jen: 16:55 Okay. So what you're saying here is that there are probably a lot of cases that are never reported.   Dr. Noll: 17:00 That's what the CDC says based on the discrepant findings. And that says a lot about our society. So are people not coming forward? Are people not recognizing that they were abused until someone asks when they're an adult? Are there not good support systems out there built in for survivors to come forward? There's layers and layers of reasons why there might be these discrepant numbers.   Jen: 17:25 Yeah. Okay. So I think we have this sort of perception because we latch onto these sort of, you know, one of media events or things that happen in the media, latch onto them and really over report them. And we have this idea in our minds that most abuse is happening or same as kind of kidnappings that somebody snatching my child off the street. It's somebody who I don't know and I have no idea that this could have happened. Whereas I was shocked in the training that I took from Darkness to Light, the Stewards of Children training, that the vast, vast majority of abuse is actually perpetrated by either a family member, which is less common admittedly, but somebody that the family knows and trusts. So I'm wondering why do young children have trouble recognizing what “good people” who do “bad things” as being abusers?   Dr. Noll: 18:18 Yeah. This is sort of the biggest question and how to prevent, because if you study these cases and the Nassar cases is a good example. What perpetrators do is they gain access to kids. They need that access and in order to gain access, they have to be trusted by the parents and they have to be in the lives of the family on a regular enough basis to be able to gain at that access. It's not just gaining access, it's deciding which child might be, let's call it groomable. When we study Sandusky, Nassar and priests, etc. etc., we learned that they first try to figure out who might be a likely candidate. So the grooming behaviors like who's amenable, who will take the gifts, who's trust can they gain, right? Those are the kinds of things, and it's not just the child, but the parents, which parents are going to allow their kids to be seen alone by the doctor, to stay the night alone with the coach, right?   Dr. Noll: 19:20 To be left alone in the company of a babysitter who might be exploiting the children. So there's lots of layers of access. And when that access happens, there's a level of trust that gets built. This is how it works. They gained the trust. You listened to Aly Raisman and she talks about this was the most trusted physician in the country for this kind of injury, right? So that trust is built and when trust is built, it's much more difficult to discern the difference between the good guys and the bad guys. When we're taught about stranger danger, that's easy. Strangers are the guys who offer you candy and snatch you off the street. They're really...