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Introduction

Medical procedures have often been used as analogues for childhood sexual abuse (CSA) and have been seen as opportunities to observe children's memories of these experiences in a naturalistic context (Money, 1987; Goodman, 1990; Shopper, 1995; Peterson Bell, in press). Medical traumas share many of the critical elements of childhood abuse, such as fear, pain, punishment, and loss of control, and often result in similar psychological sequelae (Nir, 1985; Kutz, 1988; Shalev, 1993; Shopper, 1995). It has been difficult, however, to find a naturally occurring trauma which incorporates aspects thought to be critical to the phenomenon of forgotten/recovered memories: namely, secrecy, misinformation, betrayal by a caregiver, and dissociative processes. There has been the added difficulty of finding medical events that directly involve genital contact and which accurately reflect the family dynamic in which abuse occurs.

The study which has come closest to identifying the factors likely to be involved in children's recall of CSA is a study by Goodman et al. (1990) involving children who experienced a Voiding Cystourethrogram (VCUG) test to identify bladder dysfunction. Goodman's study was unique in its inclusion of direct, painful, and embarrassing genital contact, involving the child's being genitally penetrated and voiding in the presence of the medical staff. Goodman found that several factors led to greater forgetting of the event: embarrassment, lack of discussion of the procedure with parents, and PTSD symptoms. These are precisely the dynamics likely to operate in a familial abuse situation.

The medical management of intersexuality (a term encompassing a broad range of conditions including ambiguous genitalia and sexual karyotypes) has not been explored as a proxy for CSA, but may provide additional insights into the issues which surround childhood memory encoding, processing, and retrieval for sexual trauma. Like victims of CSA, children with intersex conditions are subjected to repeated genital traumas which are kept secret both within the family and in the culture surrounding it (Money, 1986, 1987; Kessler, 1990). They are frightened, shamed, misinformed, and injured. These children experience their treatment as a form of sexual abuse (Triea, 1994; David, 1995-6; Batz, 1996; Fraker, 1996; Beck, 1997), and view their parents as having betrayed them by colluding with the medical professionals who injured them (Angier, 1996; Batz, 1996; Beck, 1997). As in CSA, the psychological sequelae of these treatments include depression (Hurtig, 1983; Sandberg, 1989; Triea, 1994; Walcutt, 1995-6; Reiner, 1996), suicidal attempts (Hurtig, 1983; Beck, 1997), failure to form intimate bonds (Hurtig, 1983; Sandberg, 1989; Holmes, 1994; Reiner, 1996), sexual dysfunction (Money, 1987; Kessler, 1990; Slipjer, 1992; Holmes, 1994), body image disturbance (Hurtig, 1983; Sandberg, 1989) and dissociative patterns (Batz, 1996; Fraker, 1996; Beck, 1997). Although many physicians and researchers recommend counseling for their intersexed patients (Money, 1987, 1989; Kessler, 1990; Slipjer, 1994; Sandberg, 1989, 1995-6), patients rarely receive psychological intervention and are usually reported as being "lost to follow-up." Fausto-Sterling (1995-6) notes that "in truth our medical system is not set up to deliver counseling in any consistent, long-term fashion" (p. 3). As a result, the intersexed child is often entirely alone in dealing with the trauma of extended medical treatment.

In cases where the intersexed child is identifiable at birth, s/he is subjected to extensive testing physically, genetically, and surgically, to determine the sex most appropriate for rearing. Kessler (1990) notes that "physicians... imply that it is not the gender of the child that is ambiguous, but the genitals... the message in these examples is that the trouble lies in the doctor's ability to determine the gender, not in the gender per se. The real gender will presumably be determined/proven by testing and the "bad" genitals (which are confusing the situation for everyone) will be "repaired"." (p. 16). Although the child is repeatedly examined through puberty, there is often no explanation given for these frequent medical visits (Money, 1987, 1989; Triea, 1994; Sandberg, 1995-6; Walcutt, 1995-6; Angier, 1996; Beck, 1997). Because both parents and physicians view these treatments as necessary and beneficial to the child, the child's trauma in experiencing these procedures is often ignored. The underlying assumption is that children who do not remember their experiences are not negatively affected. However, medical procedures "may be experienced by a child or adolescent as a trauma, with the medical personnel considered as perpetrators in collusion with the parents... the long-range effects of these events may have serious and adverse effects on future development and psychopathology" (Shopper, 1995, p. 191).

Shame and Embarrassment

Goodman (1994) notes that sexuality is characterized in children's minds primarily in terms of embarrassment and fear. Children may thus respond to all situations that carry sexual connotation with embarrassment and shame. She suggests that " children come to react to situations that carry sexual connotation by becoming embarrassed-- a shame that they are taught to feel, without necessarily understanding the reasons why. Perhaps one of the first things children are taught to be embarrassed about concerning sexuality is the exposure of their own bodies to others" (p. 253-254). Children who had experienced more that one VCUG were more likely to have expressed fear and embarrassment about the most recent test and to have cried about it since it occurred. A few even denied that they had had the VCUG.

Children experiencing other types of genital medical procedures also experience their medical procedures as shameful, embarrassing, and frightening. Medical photography of the genitals (Money, 1987), genital examination in cases of precocious puberty and intersex conditions (Money, 1987), colposcopy and examination in a girl exposed to DES (Shopper, 1995), cystoscopy and catheterization (Shopper, 1995) and hypospadias repair (ISNA, 1994) may lead to symptoms highly correlated with CSA: dissociation (Young, 1992; Freyd, 1996), negative body-image (Goodwin, 1985; Young, 1992), and PTSD symptomology (Goodwin, 1985). One of Money's patients reported "I would be laying there with just a sheet over me and in would come about 10 doctors, and the sheet would come off, and they would be feeling around and discussing how much I had progressed... I was very, very petrified. Then the sheet would go back to over me and in would come some other doctors and they would do the same thing... That was scary. I was petrified. I've had nightmares about this..." (Money, p. 717)