Inscribed Bodies: Health Impact of Childhood Sexual Abuse

Reviewed by: Jacqueline Golding, PhD


Anna Luise Kirkengen
Kluwer Academic Publishers
462 pages
ISBN 0-7923-7019-8
$139.00 US

Sexual abuse is very common. By conservative estimates, 17% of North American women and 5% of North American men were sexually abused during childhood; prevalence rates run as high as 45% of women and 16% of men in well-designed studies. Research conducted over the past few years (including Dr. Kirkengen's work in clinical epidemiology) has documented what many health and mental healthcare professionals have observed clinically for a much longer time: people who are sexually abused, especially in childhood, are at elevated risk for physical health problems.

Although several efforts are being made to understand the link between sexual abuse history and illness, Inscribed Bodies: Health Impact of Childhood Sexual Abuse is unique in portraying the transformation, within individuals, of experiences of sexual abuse into health problems. This achievement required nothing less than a profound questioning of the very assumptions of biomedicine. Dr. Kirkengen addresses these assumptions and their consequences in the first section of this brilliant, complex, and extremely important work. Dr. Kirkengen takes as a starting point the importance of "remaining faithful to the human needs that create medicine" (p. 24) as she develops an experiential framework that makes visible the connections between abuse and illness that were silenced (whether or not intentionally) by traditional assumptions. Dr. Kirkengen succeeds in articulating these connections through an understanding of the subjective meanings of abuse experiences in the lives of the women and men she interviewed, a process which facilitated "comprehending the intrinsic logic in apparently illogical reactions, responses, and processes" (p. 169). In so doing, Dr. Kirkengen concludes that "[t]he body into which violation has been inscribed, is not only a mindful body, as is valid for every lived is certainly a body 'mutely testifying' the socially silenced abuse" (p. 5). Her experiential perspective reveals "[t]he destructiveness of political or social silencing of voices ... [and] [t]he constructiveness of political or social speaking" (p. 395, emphasis in original) in the presence of trust. Readers who find Dr. Kirkengen's experiential perspective difficult at first may find it helpful to know that her conclusion is consistent with research conducted from a more traditional scientific perspective on the health-promoting effects of disclosure of trauma (most notably the work of James Pennebaker and his colleagues). Dr. Kirkengen's theoretical framework also acknowledges the powerful role of context: of the society, the participants' individual lives, and the interview setting.

The second and third sections contain clinically rich accounts of Dr. Kirkengen's in-depth interviews with 32 women (ages 16 to 70) and 4 men (ages 27 to 56) who were recruited through 2 incest centers in Norway. Both the participants' accounts of their personal histories and their reflections on them, and Dr. Kirkengen's accounts of her experiences of interviewing these women and men, are deeply moving. Dr. Kirkengen successfully holds simultaneously the immediacy of the participants' experiences and the theoretical framework within which she discusses them.

The second, and longest, section describes the connections that emerged in the interviews between sexual abuse and illness and the ways in which the participants' experiences of abuse became embodied. Dr. Kirkengen identifies 7 themes in the participants' accounts, each of which she describes in the lives of multiple respondents. She terms these themes lived meanings, confused judgments, maladaptive adaptations, strained relationships, recognized memories, unheard messages, and reactivated experiences. For example, in the section on lived meanings, she describes the experiences of Berit, who was abused during childhood and adolescence by her mother's boyfriends. Berit's health problems include serious infections in her throat. She recounts how one of the offenders would "put a knife to my neck ... and after that, all he needed to do was to place a finger there ... I knew what this meant: 'now your mother leaves for her job and I'll send your brother out and then I'll take you'" (p. 122). "The finger 'meant' abuse, powerlessness, and the futility of resistance ... She was his property" (p. 123). Dr. Kirkengen observes that Berit clears her throat, breathes deeply, and swallows loudly during the interview, and recounts that Berit avoids things that might touch her neck, such as scarves and necklaces. Commenting that the connection seemed "almost too concrete and too direct" (p. 123), wondering, "Could it be so astoundingly simple?" (p. 123), Dr. Kirkengen understands these as continued effects of the knife against Berit's neck.

In the third section, Dr. Kirkengen explores the participants' experiences with healthcare. Participants often describe a sense that healthcare providers are unaware of, or reluctant to discuss, the participants' histories of abuse. This is important in part because "[v]iolated humans are made sick by the silence" (p. 390, emphasis in original). Another significant aspect of medical help-seeking for patients who have been abused is the "link between the private experience of being made to feel worthless ... and the public doom of being unworthy to receive help" (p. 392, emphasis in original). Dr. Kirkengen also documents instances of abuse by physicians, and addresses the role of medical evidence (and its dependence on the positivist scientific notion of proof) in legal prosecution of sex offenders. She describes the effects of this knowledge on her feelings about her professional identity.

The vast majority of people who have been sexually abused (84% to > 98%) have never told a physician about the abuse. The implication is that a tremendous number of physicians have in their practices patients who have been sexually traumatized, have never told the physician, and have health problems related to the abuse. It is my opinion that physicians who read Dr. Kirkengen's important work will be far better prepared to understand and address the role of sexual abuse in their patients' health problems -- to the great benefit of both patients' health and physicians' frustration levels. At the very least, physicians' perspectives on their patients will be profoundly changed after having read this book. The book's transcripts of Dr. Kirkengen's interviews with participants could usefully serve as examples of sensitive interviewing techniques.

Psychotherapists in all professions who are working with sexually abused clients can benefit significantly from the increased understanding of the role of trauma history in their patients' physical health. Sexual abuse researchers in all fields who read this book will better understand the experience of sexual abuse and its relationship to health problems.

Dr. Kirkengen is a general practitioner (the American equivalent is a physician specializing in family medicine) who has many years of clinical experience and legal advocacy in working with sexual abuse survivors. She also has a PhD in women's health (known in European contexts as a dr. med). She provides postdoctoral training to physicians training as family medicine specialists.


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