Childhood sexual abuse is increasingly invoked as the causative agent for a broad spectrum of disorders, especially in woman, ranging from depression through eating disorders to such complex personality configurations as the borderline conditions and multiple personality disorder. More and more troubled people are "remembering" sexual violations, often under the supportive, encouraging, even coercive influence of therapists who are certain that the evocation and abreaction of such memories is the sin qua non of the therapeutic success. The topic has become a staple of television talk shows, which disseminate the word worldwide. Such unitary etiological concepts are, of course, nothing new; diabolical influences, "hereditary degeneration," exposure to the "primal scene" - each has had its day, has enjoyed its vogue, and has either passed into the dustbin of history or assumed its appropriate place in the etiological spectrum.
[...] All of the studies in this field, whether if clinical (i.e.,patient) populations or of normative community samples, have been based on data derived from questionaires (as in Kinzl's article) or from retrospection in either clinical or research interviews ( as in the article by Rorty and colleagues). The limitations of both of these methods are well-known and acknowledged by the authors. Overreporting, underreporting, retrospective distortion, tendentious recollection, responses to overt or implied suggestion - all may play a part in skewing the data, requiring a substantial measure of reserve in their interpretation. This is all the more true in the present climate, in which the information and entertainment media are replete with stories, often lurid, of the prevalence and the dire consequences of abuse. Even when clinicans and researchers do not implant or provoke such "memories", the very culture itself offers suggestions that may help to shape the subjects' theories of pathogenesis. Shengold and Raphling have reported cases in which initial complaints of sexual abuse (likely to have been reported as such on questionaires or in research interviews) proved in the course of psychoanalysis to be unfounded.
[...]The conclusions of Welch and Fairburn's study, similar to those of Palmer and Oppenheimer, differ from thos of Pope and Hudson. Clearly, thus, the returns are far from in and probably will be until the completion of systematic prospective studies that are free from recall bias, the effects of psychotherapy in clinical subjects, and the multitude of other potential sources of error described by Gutheil.
Perhaps the issues have been most cogently drawn by Kendell-Tacket et al. in a recent review of empirical studies in this realm. "A glaring inadequacy in the literature" they point out, "is a nearly universal absence of theoretical underpinning. ... researchers studying childhood sexual abuse have looked in isolation at many factors related to the impact of abuse. Now it is time for us to combine them into more realistic models." (pp. 174 and 176). In short, some careful reflection is needed to transcend the impact of the initial reports of the long-range pathological effects of abuse, physical and sexual, and to develop a reasoned, scientifically founded conceptualization of the relation of psychiatric disorder to the many ills to which flesh is heir - one that takes account of the principle of multiple determination of behaviour and does not leave up victim to that most seductive siren call, blame assignment. The history of the notion "schizophrenogenic mother" should alert us to the perils of uncritical and overzealous attribution of pathogenic agent to the "abusive father". It is wise, proper, and humane for us to hear what our patients tell us; it is unwise, improper, and hazardous for us to tell them what we want to hear.
Dr. Esman