“As an undergraduate student in psychology, I was taught that multiple personalities were a very rare and bizarre disorder. That is all that I was taught on ... It soon became apparent that what I had been taught was simply not true. Not only was I meeting people with multiplicity; these individuals entering my life were normal human beings with much to offer. They were simply people who had endured more than their share of pain in this life and were struggling to make sense of it.”
― Deborah Bray Haddock, The Dissociative Identity Disorder Sourcebook
Many types of trauma exist, including natural disaster, medical trauma, assault, bullying, abuse, domestic violence, gang violence, war, terrorism, institutional prejudice, and human trafficking. However, dissociative identity disorder (DID) can only be caused by repeated or long-term childhood trauma. According to the DSM-5, around 90% of individuals with DID have experienced child abuse or neglect. Other forms of childhood trauma that are associated with DID include medical and surgical procedures, war, human trafficking, and terrorism (American Psychiatric Association, 2013)1.
Betrayal traumas, or traumas which involve a significant violation of trust or wellbeing by individuals or institutions that an individual relies on for survival (Freyd, 2014)2, are more likely to lead to DID than are non-betrayal traumas (Spiegel, 2008)3. Child abuse and neglect are types of betrayal trauma while natural disasters and medical procedures are not. For adults, traumas like stranger rape are not automatically betrayal traumas, but they can become such if one’s existing support system, the institution in which the rape occurred, or the legal system fails to show support or reacts in a very negative or shaming manner. In all of these cases of betrayal trauma, the victimized individual cannot acknowledge the harm being done to them or withdraw from those hurting them without risking harm or, in the case of an abused or neglected child, even death. It should be noted that self-reported betrayal has been found to predict PTSD and dissociative symptoms better than fear. Betrayal traumas are in general more likely to cause “betrayal blindness,” or repressed/dissociated memories, than non-betrayal traumas are (Freyd, 2014)2. A leading researcher on betrayal traumas is Jennifer J. Freyd.
Other significant factors in the impact of trauma and development of DID include the age of the child, the severity of the trauma, what additional traumas or stressors are present in the child's life, how naturally dissociative the child is, and the child's relationship with their caregivers (Spring, 2012)4. Children who have insecure or disorganized attachment with caregivers are more at risk for identity confusion, dissociative disorders, borderline personality disorder (Gonzalez, Gonzalez, & Van der Hart, 2012)5, and reactive attachment disorder (Bremness, 2003)6. Many of the same factors (namely, whether or not the trauma is long-term or repeated, interpersonal, severe, happening to a child, or happening to a severely dissociative individual) also make one more vulnerable to developing complex-posttraumatic stress disorder instead of posttraumatic stress disorder (van der Kolk, 2001)7.
Emotional and verbal abuse- Emotional abuse is abuse that affects a child psychologically and socially. Though it accompanies physical and sexual abuse, it can happen independently as well. Emotional abuse is the most common type of child abuse. Unfortunately, it is often covert and can be hard to recognize, especially in the absence of explicit verbal degradation (Blue Knot Foundation, 2015)8. Emotionally abusive adults might focus on their own needs before those of the children in their care. Though they might resort to verbal threats, insults, humiliation, or intimidation, they might also engage in emotional blackmail or manipulation, isolate the child, or display unreasonably demanding, overly controlling, or possessive behaviors. Emotional abuse might also manifest as emotional neglect, abandonment, or rejection in which the child's physical needs are met but their emotional needs are ignored or dismissed. Exposing a child to the abuse of another individual (including domestic violence or spousal abuse) or to violence towards a pet is another type of emotional abuse (Blue Knot Foundation, 2015; Smith, & Segal, 2016; American Humane Association, n.d.; Petro, n.d.)8,9,10,11.
Neglect- Neglect occurs when a caregiver fails to adequately provide for a child's needs. This might involve failing to provide food, shelter, or clothing; appropriate medical and dental care; love and support; age appropriate supervision and control; moral and legal guidance; or a way or incentive for the child to regularly attend school (Blue Knot Foundation, 2015)8. Some parents are financially, mentally, or emotionally unable to provide adequate care for their children, and this along with substance abuse and addiction are common contributors to neglect. Neglect might force older children to look after themselves, younger siblings, or even their parents in a type of abusive role reversal (Smith, & Segal, 2016)9.
Physical abuse- Physical abuse involves deliberate violence or inappropriately severe punishment against children that results in physical harm or injury (Smith, & Segal, 2016)9. Examples include hitting, slapping, punching, kicking, biting, burning, scalding, striking a child with an object, or threatening or attacking a child with a gun or knife. Physical abuse most often results in death for infants or toddlers, but it can cause permanent harm for all age groups (Blue Knot Foundation, 2015)8. Unlike appropriate discipline (which physical abuse is often excused as), physical abuse is unpredictable, done out of anger, or meant to cause fear in the child being harmed. It does not appropriately take into account the child's age or physical condition (Smith, & Segal, 2016)9.
Sexual abuse- Sexual abuse involves an adult engaging a minor in a sexual act or exposing the minor to inappropriate sexual behavior or material, or it can involve another minor coercing or forcing a child into sexual activity. Sexual abuse may involve threats or physical force, but it may also involve manipulation. Sexual abuse is slightly more common for female than for male children, but male children are also frequently sexually abused, and physically, mentally, or developmentally disabled children are most at risk (Blue Knot Foundation, 2015)8. As with all other types of abuse, both females and males can be perpetrators, and most perpetrators are known to the victim (National Center for Victims of Crime, n.d.)12.
Covert sexual abuse- Though harder to recognize than overt sexual abuse, covert sexual abuse is just as valid and harmful as abuse that involves explicitly inappropriate touching. Touch in covert sexual abuse might involve the neck, stomach, or thighs instead of genitalia or might involve an adult kissing a child with too much passion or for too long. Without ever explicitly mentioning sex, the adult might make comments about the child's sexuality, talk about their body in a sexual manner, make flirtatious comments, or treat the child as a replacement spouse or complain to the child about their marriage or sex life. The adult might watch older children bathe or change outfits long after the child stopped requiring help or supervision with such things. The child might not be given privacy when in the restroom or might not be protected from seeing the adult naked or changing (Weiss, n.d.; Weiss, 2015)13,30.
Organized sexual abuse- Organized sexual abuse is sexual abuse that often involves multiple child victims and multiple adult perpetrators. This can manifest as sexual abuse in a religious setting or as part of a religious cult, in another institutional setting such as a group home, as a child sexual abuse ring, or as domestic minor human trafficking (Blue Knot Foundation, 2015; Salter, n.d.)8,31. In many cases, children are primarily abused by a family member, such as their father, who invites others to also sexually abuse them. According to one of the leading researchers on organized abuse, Michael Salter, up to 1/5 of sexually abused women and children in clinical settings report this type of abuse when asked, although only 3% of sexual abuse-related reports to child protective services reference organized abuse (Salter, n.d.)31.
Religious/Spiritual abuse- Religious abuse can refer to abuse with religious components or overtones, to abuse perpetrated by a religious institution, or to religious cult abuse. Abuse with religious aspects or overtones might involve the use of bible verses to justify sexual abuse, physical abuse, emotional abuse, or neglect (Child Friendly Faith Project, n.d.)14. Threats of hell or damnation might be used to terrify children into compliance, or talk of demons or possession might cause children to fear their own minds, comply with abuse, or fail to seek help or treatment for physical or mental disorders or disabilities. Sometimes, religious institutions will knowingly allow or covertly or overtly sanction abuse within their community or engage in organized sexual abuse or human trafficking. Religious cults might engage in intense religious indoctrination and conditioning along with physical, sexual, and emotional abuse. Further examples of abuse that are often "justified" by religion include medical neglect, child marriage, exorcism, genital mutilation, conversion therapy for LGBT youth, or abandoning a minor for reasons such as the minor being LGBT or having differing religious beliefs (Bulwer, 2016)15.
Ritualized abuse- Ritualized abuse is abuse that's done in a ritualistic manner. This most often refers to organized abuse with ritualistic aspects although it's sometimes used to refer to any sadistic or severe abuse that involves a mixture of physical, sexual, and psychological abuse. Ritualized abuse may involve a group ideology, but such an ideology may be staged in order to deceive and threaten victims. Though this is most often said to be associated with Satanism and Satanic ritual abuse (SRA), it has also been associated with allegedly Gnostic, Christian, and fascist groups (Becker & Coleman, 1999)16. Contrary to popular belief, ritualized abuse does not necessarily involve cults, ritual worship, or bizarre sexual activities. Instead, ritualized abuse might make use of sadistic abuse, real or staged acts of extreme violence, and/or religious symbols in order to silence or discredit child victims of more "mundane" types of abuse or, in cases of human trafficking, in order to produce certain types of child pornography. According to Dutch researchers Onno van der Hart, Suzette Boon, and Olga Heijtmajer Jansen, "Dutch clinicians increasingly have gotten the impression that many of these so-called SRA groups are linked with syndicated child-sex rings ... and other forms of organized crime. SRA activities seem to be a screen-- evoking disbelief among law enforcement agencies and other parties when reported-- as well as a means to ensure loyalty in victims, which is accomplished by instilling terror and guilt" (1997)17.
Domestic minor human trafficking- The Trafficking Victims Protection Act 2000 defines sex trafficking as “the recruitment, harboring, transportation, provision, or obtaining of a person for the purpose of a commercial sex act where such an act is induced by force, fraud, or coercion, or in which the person induced to perform such act has not attained 18 years of age", further defining a commercial sex act as "any sex act on account of which anything of value is given to or received by any person." Similarly, the act defines labor trafficking as "the recruitment, harboring, transportation, provision, or obtaining of a person for labor or services, through the use of force, fraud, or coercion for the purpose of subjection to involuntary servitude, peonage, debt bondage, or slavery" (Office on Trafficking in Persons, 2012)18. Domestic minor human trafficking occurs when citizens or lawful permanent residents who are under the age of 18 are subjected to the above (Shared Hope International, n.d.)19. Children especially vulnerable to human trafficking are those who "have already experienced abusive or troubled families; have disabilities; come from families with very limited resources; have run away; are involved in the juvenile justice, dependency, or foster care systems; or are estranged from protective networks because of their LGBT identity" (Harpster, 2014)20. Age is another factor that makes children more vulnerable (Shared Hope International, n.d.)19.
Sex trafficking of minors can involve prostitution, pornography, and/or erotic entertainment such as stripping, pole dancing, or erotic massage (Houston Rescue and Restore Coalition, 2011)21. Force, fraud, or coercion are not necessary for the crime to be considered human trafficking when a minor is the victim (Shared Hope International, n.d.)19. Human trafficking is a separate issue from human smuggling, and no borders need to be crossed for the crime to be considered human trafficking (Office on Trafficking in Persons, 2012)18. Domestic minor sex trafficking is a very real problem everywhere, including wealthy Western nations. Though there is no official estimate on the number of victims of human trafficking in America, Polaris estimates the total to be in the hundreds of thousands (2015)22, and one third of these victims are thought to be children (United Nations Office on Drugs and Crime, 2014)23. Additionally, child pornography is one of the fastest growing businesses online and was a $3 billion annual industry by 2005. Of the 1,536 child pornography domains that were known in 2008, 58% were hosted in the US (Enough is Enough, n.d.)24. Both male and female children are forced into sex trafficking, and traffickers can be either female or male (Polaris, n.d.)25.
Identifying trafficked children is harder than many might assume. Child victims may not understand that they're being abused, especially if they believe themselves to be in a relationship with their trafficker. They may think that they share the blame for their abuse and that they're breaking the law. They may fear that if they speak up, they, their family, or other innocent people will be hurt. They may have been taught to fear authority and the legal system. If the victim was trafficked from another country, they may fear being returned to an even less safe environment. They may fear that their family or community will judge them, not want to implicate involved family members, or believe that their family needs the money they may be earning from the child's forced labor or sexual exploitation. If the child does try to disclose, this may be complicated by PTSD; dissociative amnesia; confusion about what happened to them; difficulty discerning reality due to drugs, stress, young age, or being deliberately misled about their experiences; or lack of proficiency in English. Sometimes, minors are wrongly treated as criminal suspects or are even prosecuted for the nature of their victimization or the things that they were forced to do as part of their victimization (National Society for the Prevention of Cruelty to Children, n.d.)26.
Warning signs for abuse often overlap between types of abuse. General signs of child abuse include distress, anxiety or depression, eating disorders, aggressive or antisocial behavior, extreme compliance or defiance, emotional detachment or dissociation, clinginess, difficulties with academic achievement and school attendance, extreme fear regarding making mistakes or doing something wrong, acting out and constantly doing things wrong or getting into trouble, expressed fear or unwillingness to return home, running away from home, difficulties making and keeping friends, expressed feelings of worthlessness or being bad or damaged, risky behaviors or drug or alcohol use, and self harm or suicidal threats or gestures (Blue Knot Foundation, 2015; Smith, & Segal, 2016; American Humane Association, n.d.; National Society for the Prevention of Cruelty to Children, n.d.)8,9,10,26.
Additional signs of physical abuse can include frequent or unexplained injuries (including bruises, burns or scalds, bite marks, fractures or broken bones, scarring, signs of poisoning, signs of having been drowned or suffocated, or signs of an infant having been shaken), wearing inappropriate clothing meant to cover up injuries, fear of being touched or shying away or flinching in response to touch or sudden movements, mysterious pains, and abnormal physical development and coordination. Additional signs of neglect can include ill-fitting, filthy, or inappropriate clothing, consistently poor hygiene, untreated illnesses or injuries, recurring illnesses or infection, a frequent lack of adult supervision that may lead to accidents or injury, not meeting developmental milestones, being short and underweight (failure to thrive), and malnourishment or being underfed. Additional signs of sexual abuse can include difficulties walking or sitting, age inappropriate sexual knowledge or behaviors, strong efforts to avoid a particular person for no known reason, intense anxiety regarding changing clothing in front of others, an STD or pregnancy, incontinence or bed wetting, and nightmares. Additional signs of human trafficking can include a child having no free time or freedom of movement, not knowing what city or even country they are in, not being able to give personal details or tell where they are living, not being registered with a school or any doctors, having no documents or falsified documents, being seen in a brothel or factory, injuries from workplace accidents, or being frequently seen with an unknown or non-familial adult who may try to speak for them (Blue Knot Foundation, 2015; Smith, & Segal, 2016; American Humane Association, n.d.; National Society for the Prevention of Cruelty to Children, n.d.)8,9,10,26.
It should be noted that not all abuse occurs within the home environment. Other signs of abuse may include a child displaying extreme fear of school, church, a daycare center, an extended family member or family friend's house, or another such environment; fearing or avoiding particular individuals associated with or working at such environments (BabyCenter Medical Advisory Board, 2014)27; or trying to avoid such environments through claiming to be ill or even trying to cause illness or injuries to themselves to avoid having to go (Blanco, 2011)28. Note that young children who are frightened of going to see an abuser or going to an abusive environment may genuinely mistake the physical signs of fear or anxiety for proof that they're ill (Campbell, 1991)29 and that prolonged stress can weaken the immune system and make illness more likely (Blanco, 2011)28.
Adults who were abused as children are more likely to experience mental and physical health problems and to struggle with emotional dysregulation. Posttraumatic stress symptoms may prove especially problematic. Abused adults may have difficulties forming relationships with others may become abusers themselves or be continually re-victimized by others. They are also at increased risk for suicidal attempts and substance abuse (Blue Knot Foundation, 2015; National Society for the Prevention of Cruelty to Children, n.d.)8, 26.
Whether or not one is a mandatory reporter, anyone who witnesses or comes to suspect child abuse (including human trafficking) should report it to the proper authorities. It cannot be assumed that every instance of child abuse will be obvious or that every child will eventually tell an adult who is willing to act on their behalf about the abuse. Abusive families might seem normal or even happy from the outside, and children might be good at hiding the abuse, feel that no one would believe them if they told, or have already told someone in the past who reacted poorly or failed to help them. If you have reason to suspect that a child is being abused, report the abuse yourself. Information about reporting abuse can be found here.
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3 Spiegel, D. (2008). Coming apart: Trauma and the fragmentation of the self. Retrieved from http://www.dana.org/Cerebrum/2008/Coming_Apart__Trauma_and_the_Fragmentation_of_the_Self/
4 Spring, C. (2012). What causes dissociative identity disorder? Retrieved from http://www.pods-online.org.uk/index.php/information/articles/faqs-dissociation/what-causes-dissociative-identity-disorder
5 Gonzalez, D., Gonzalez, A., & Van der Hart, O. (2012). Borderline personality disorder, childhood trauma and structural dissociation of the personality. Revista Persona, 11(1), 44-73.
6 Bremness, D. (2003). Attachment Disorganization [Review of the book Attachment Disorganization, by J. Solomon & C. George [eds.]]. Journal of the Canadian Academy of Child and Adolescent Psychiatry, 12(3), 93. doi:10.1126/science.290.5495.1304
7 Van der Kolk, B. A. (2001). The assessment and treatment of complex PTSD. In R. Yehuda (Ed.), Traumatic stress. American Psychiatric Press.
8 Blue Knot Foundation. (2015). Types of child abuse. Retrieved from
9 Smith, M., & Segal, J. (2016, March). Child abuse and neglect. Retrieved from http://www.helpguide.org/articles/abuse/child-abuse-and-neglect.htm
10 American Humane Association. (n.d.). Emotional abuse. Retrieved from http://www.americanhumane.org/children/stop-child-abuse/fact-sheets/emotional-abuse.html
11 Petro, L. (n.d.). Types of emotional abuse. Retrieved from http://www.teach-through-love.com/types-of-emotional-abuse.html
12 National Center for Victims of Crime. (n.d.). Statistics on perpetrators of child sexual abuse. Retrieved from https://victimsofcrime.org/media/reporting-on-child-sexual-abuse/statistics-on-perpetrators-of-csa
13 Weiss, R. (n.d.). Childhood covert incest and adult life. Retrieved from https://blogs.psychcentral.com/sex/2014/07/childhood-covert-incest-and-adult-life/
14 Child Friendly Faith Project. (n.d.). Our mission. Retrieved from http://childfriendlyfaith.org/mission/
15 Bulwer, P. (2016, February 23). A snapshot of religion related child abuse from June 2007 to June 2011. Retrieved from http://religiouschildabuse.blogspot.com/2016/02/a-snapshot-of-religion-related-child.html
16 Becker, T. & Coleman, J. (1999, May). Ritual abuse: An European cross-country perspective. In The Spectrum of Dissociation. Presentation conducted at the ISSD Spring Conference, Manchester, UK.
17 Van der Hart, O., Boon, S., & Jansen, O. H. (1997). Ritual abuse in European countries: A clinician's perspective. In G. A. Fraser (Ed.), The dilemma of ritual abuse: Cautions and guides for therapists (1st ed., Clinical Practice, pp. 137-163). Washington, DC: American Psychiatric Publishing.
18 Office on Trafficking in Persons. (2012, August 2). Fact Sheet: Human Trafficking. Retrieved from http://www.acf.hhs.gov/programs/endtrafficking/resource/fact-sheet-human-trafficking
19 Shared Hope International. (n.d.). FAQs. Retrieved from http://sharedhope.org/the-problem/faqs/
20 Innocence for sale: Domestic minor sex trafficking (2014) (testimony of Michael T. Harpster). Retrieved from http://www.fbi.gov/news/testimony/innocence-for-sale-domestic-minor-sex-trafficking
21Houston Rescue and Restore Coalition. (2011). Rapid field assessment of domestic minor sex trafficking in Harris and Galveston Counties, Texas. PIP Printing.
22 Polaris. (2015). The facts. Retrieved from https://polarisproject.org/facts
23 United Nations Office on Drugs and Crime. (2014). Global report on trafficking in persons. Vienna: United Nations Publications.
24 Enough is Enough. (n.d.). Statistics. Retrieved from http://www.enough.org/inside.php?tag=statistics
25 Polaris. (n.d.). Human trafficking. Retrieved from https://traffickingresourcecenter.org/type-trafficking/human-trafficking
26 National Society for the Prevention of Cruelty to Children. (n.d.). NSPCC. Retrieved from https://www.nspcc.org.uk/
27 BabyCenter Medical Advisory Board. (2014, March). Child abuse: How to tell if something's wrong. Retrieved from http://www.babycenter.com/0_child-abuse-how-to-tell-if-somethings-wrong_6210.bc
28 Blanco, J. (2011, May 12). How to spot a bullied child and what to do [Editorial]. CNN. Retrieved from http://www.cnn.com/2011/OPINION/05/12/blanco.bullying/
29 Campbell, S. (1991, March 15). Fake illnesses may signal deeper problem. Los Angeles Times. Retrieved from http://articles.latimes.com/1991-03-15/news/vw-129_1_physical-symptoms
30 Weiss, R. (2015). Understanding covert incest: An interview with Kenneth Adams. Retrieved from https://www.psychologytoday.com/blog/love-and-sex-in-the-digital-age/201510/understanding-covert-incest-interview-kenneth-adams
31 Salter, M. (n.d.). Information about organised abuse. Retrieved from https://www.organisedabuse.com/info
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