Lasting damage

Click.

That simple sound is enough to send some women into a panic as memories of their abuser unlocking the front door surface in their minds. For these women, such a noise can transport them back to their childhoods -- to the many nights they lay awake in terror, waiting for their perpetrator to act, not knowing when it would happen, how long it would last, or how much it would hurt.

According to Jennie Noll, professor of human development and family studies and director of research and education for the Network on Child Protection and Well-Being, some 70,000 to 100,000 girls are sexually abused in the United States each year, and those are just the cases that are reported. Noll believes these egregious sexual violations can have long-term effects on health and development that are different from the effects of other kinds of childhood abuse.

"The kind of stress caused by sexual abuse is unpredictable, yet constant and extreme," says Noll. "It starts early in life when physiological systems are developing and their future organization and function are being established. It is the kind of stress that never quite goes away, even when the danger subsides. As a result, it has significant wear and tear on the body, including on the brain and on multiple endocrine and neurobiological systems."

To investigate the unique effects of childhood sexual abuse, Noll conducts longitudinal -- or long-term -- studies of girls who have been sexually abused and compares them to girls who have similar backgrounds, including family makeup and neighborhood origin. Such a "prospective" study design enables Noll to observe outcomes as they happen rather than "retrospectively" looking into the past to see what may have caused a particular outcome, a design approach that often is criticized for being biased and leading to inaccurate results.

"People at the legislative level sometimes argue that we don't know if it's abuse or poverty or the family situation that causes health problems, so why would we put our money into dealing with something that we can't make strong inferences about?" says Noll. "The kind of prospective research that we do is the best kind of research we can offer to demonstrate that childhood sexual abuse causes certain public health problems."

Long-term health consequences

Depression. Substance abuse. Liver disease. HIV. Katie [not her real name] is suffering from a multitude of health problems, perhaps directly attributable to the sexual abuse she endured as a child.

"Beginning at age 10, Katie's stepfather engaged her in a non-violent sexual relationship under the auspices of love," says Noll. "When her mother was not at home -- which was a lot because her mother worked nights -- he would ask for sex and they would have intercourse. He did it by convincing her that it was part of being loved, that he loved her so much that having sex with her was one way that she could know that she was loved. This can be very confusing for a young girl who may feel as though she participated in the sexual relationship in a way or somehow gave consent. But as we know, no child can give consent for sex."

According to Noll, this abuse set Katie -- a participant in one of Noll's studies -- on a trajectory that led to several incidences of revictimization and numerous health problems. After graduating from high school, she enlisted in the military, where she was raped several times. Her resulting post-traumatic stress disorder symptoms eventually interfered with her ability to do her job, and she ended up being discharged from the service before her tour was over.

When she returned to the United States, Katie began to drink heavily and to use methamphetamines. She was involved in a number of additional sexual assault situations and had some trouble with the law. Now in her late 30s, she is struggling to hold down a job and does not have a stable relationship. Her health is starting to fail.

"When I asked her what has been the biggest barrier in her life, what has gotten in the way of her being able to function and be happy, she said it was the sexual abuse that she suffered as a child, because it set her on a course of victimization and misery and psychological problems that she's never fully recovered from," says Noll.

Katie's HIV, liver disease, substance abuse, and depression are just a few of the negative health outcomes that often are associated with childhood sexual abuse, according to Noll. "Obesity, diabetes, cancer, and cardiovascular disease also appear to be related to abuse," she says.

In one study, Noll has been following a group of 90 sexually abused females, as well as 90 matched comparison females, all of whom were recruited by scientists at the National Institutes of Health in the late 1980s, when the participants were around 10 years old (Noll joined the project in 1995). The women now are entering their late 30s and early 40s. Among many other health measures, Noll has been tracking the participants' cognitive abilities by conducting memory, reasoning, and vocabulary assessments over the years.

"We are beginning to see premature cognitive aging and early signs of cognitive decline, although none of these women have even reached the age of 45," she says. "These findings are consistent with what we believe to be the later-life manifestations of early brain maldevelopment and evidence for the neurobiological consequence of early and chronic stress."

Noll also has been measuring the women's body mass and has found that 42 percent of the abused females were obese by late adolescence, while only 28 percent (the national average) of the comparison group were obese. Noll suspects that, perhaps as a result of the high rates of obesity, the abused women may also exhibit higher rates of diabetes, high blood pressure, heart problems, and cancer. She is currently investigating those possible health outcomes.

In addition, Noll's work has shown that sexual abuse victims are more likely to suffer from depression and substance abuse problems, to be raped in late adolescence and early adulthood, and to experience domestic violence.

"The abused girls are two-to-three times more likely to be revictimized than the comparison girls," says Noll.

Crossing generations

Perhaps even more disturbing than the pain these women continue to experience is the suffering that is passed on to their offspring. According to Noll, 20 percent -- twice the national average -- of the abused women in her sample gave birth to premature babies. Noll's data suggest that the premature status of these babies is due to the abused mothers' high cortisol levels as a result of stress and/or alcohol abuse during pregnancy.

In addition, as the children of abused mothers age, they are more likely to enter child protective services, to score significantly lower on cognitive ability tests than children of comparison mothers, and to suffer from sexual or physical abuse.

"Typically, it isn't the mom who goes on to abuse the kids," says Noll. "That's the myth that I've been able to dispel with this study. More often, there's an environment that's recreated wherein kids are put at risk for being exploited by other people who have been brought into that family system, or the mother is neglectful. Because we've followed this sample for so long, we have some of the only data on how the abuse experience of the mother confers risk to her offspring."

Noll's data show definitively that childhood sexual abuse has long-term health and wellness impacts, but do the frequency, severity, or age at onset of abuse also have effects?

"It's very difficult for us to put a judgment on how people interpret their traumatic experiences," says Noll. "One traumatic experience may be pretty severe for one person, while another person may have had really severe and repeated trauma that does not impact them much. It's very individual. The outcome often has to do with how resilient the victims are. Anecdotally, those who were able to remove themselves from the situation, who were able to find solace in a strong female role model or in religion, or who just had the kind of personality that allows them to say, 'This abuse is not going to define me or stop me,' tend to do better. One definitive thing our data show is that the girls who did not experience physical threats, but instead had a lot of confusion about what their role was in the relationship, do the worst long-term."

Online victimization

An image of a pair of breasts, a name scribbled across the flesh. This is the publicly available Facebook profile picture of a 15-year-old girl -- with 1,500 Facebook friends -- who is part of Noll's latest study on the effects of childhood sexual abuse on Internet and social media behaviors.

To conduct the study, Noll recruited 450 girls, ages 12 to 17, 150 of whom were victims of sexual abuse that was reported and substantiated in a court of law within the year prior to their involvement in the study. The remaining 300 girls were either matched comparison girls or census-matched girls. Noll gave each of the girls a laptop computer and told them they could do whatever they wanted with it. She is currently tracking and recording every URL visited, search term entered, and social media post made, among other things.

"So far, I have noticed something very peculiar about the publicly available profile pages of the girls from the sexually abused group," says Noll. "They are much more provocative in their self presentations and revealing in terms of personal identifying information than the comparison girls. Their pages are suggestive of an individual who might be willing to entertain sexual advances online."

Noll says that "creepers" choose vulnerable adolescents to lure offline and may even find them by looking for provocative profile pictures. She has found that about 30 percent of the adolescents in all groups in her studies have gone to meet someone offline whom they first met online. She also has found that only 2 percent of parents in both the abused and comparison groups implemented a parental control device on their daughter's computer, even when Noll and her team gave them explicit instructions on how to do so.

"Parental control is the primary means of prevention for keeping kids out of pornography and other dangerous online behaviors, and that's not happening," says Noll. "We need to equip our kids to monitor their own behavior, especially those who are the most vulnerable, like abused kids who are often not fully aware that they have the power to protect themselves from perpetrators who seek victims online."

Influencing policy

Noll often has to intervene when she sees problems occurring among her study participants. "We are mandated to report to authorities if we see a child whom we suspect is being abused or a woman who is depressed, suicidal, has psychiatric conditions, or is abusing her own kids," says Noll.

But Noll's hopes extend beyond just helping her own study participants. She wants to make a difference for sexual abuse victims throughout the nation. To do so, she works with policy makers, such as those in the Pennsylvania General Assembly, to help them better understand the impacts of sexual abuse and to write legislation that protects victims and may even prevent abuse from happening in the first place. She also works with the National Institutes of Health to help establish funding priorities so as to bring about systemic change in the area of childhood sexual abuse.

"People really won't pay attention unless we have rigorous scientific evidence," says Noll. "We need to use this evidence as the basis for policy changes. We especially want Pennsylvania to be a major player in research that can change the lives of these victims."

Watch this video conversation with Jennie Noll for more information.