Working with adult survivors of child sexual abuse.

Many people who have been sexually abused as children present for help in adult life still suffering the emotional legacy of their traumatic experience.' Increasingly, some present themselves directly as victims of sexual abuse in childhood; others turn up with various psychiatric or gynaecological symptoms or general poor health-the history of sexual abuse comes to light only as treatment continues.In these circumstances, intense feelings may arise between the doctor and patient, which offer insights that can be used to help the patient.An analysis of the doctor-patient relation- ship gives a glimpse of the patient's childhood relationships and how pathological these may have been.An understanding of these may improve the treatment's chance of success, helping the doctor to avoid the pitfalls that can so easily sabotage treatment.Given the highly exploitative and damaging relationships that these patients have experienced, they find it difficult to trust their doctor.2Thus they may respond defensively to anything even slightly reminiscent of abuse-such as an intrusive question or a well intentioned attempt to coerce them into treatment.Patients may seem oversensitive to any suggestion that what they say is not being believed or taken seriously enough.They may feel desperately let down by any perceived neglect such as being kept waiting or having a small detail forgotten.Sometimes they respond with anger; more commonly they simply fail to return for treatment.Particularly important to this group of patients is the gender of the doctor.With male doctors they will mistrust any hint of an erotic dimension to the relationship.They also have a tendency to abdicate power to men and then feel frightened.They are likely to perceive women doctors as not "good enough" and to respond to them with anger, frustration, and disappointment.3Their doctors' care and concern in their problems invokes grief at the lack of adequate nurturing that they received in childhood.Doctors therefore find themselves steering a fine line between being "intrusive" on the one hand and "neglectful" on the other.Many patients grew up in families where normal social roles were grossly distorted; not only do they feel confused about their own role but they also perceive other people as confused in their roles.Some patients were abused before they had developed a consistent sense of themselves as separate people and before they had acquired a vocabulary to describe what was happening.They are particularly prone to being swamped by emotions and physical sensations and experience difficulty putting their problems into words.