Kremer 2013
Kremer 2013
Kremer 2013
This study tries to understand the differences in body experience between victims of sexual
abuse and physical abuse. Ninety-eight women completed questionnaires that measured
personal information, body-image aberration, body sensitivity and control, and body
investment. Findings indicated that victims of sexual abuse demonstrate less body main-
tenance and protection in addition to greater injury to body sensitivity and control than
victims of physical abuse. Moreover, comparing victims of sexual abuse to physical abuse,
findings revealed that only victims of sexual abuse report body-image aberrations. Thus,
sexual and physical abuse should be addressed discretely because each has differential
effects on bodily attitudes of victims.
T
he goal of this study was to refine the current understanding of the differences in
body experience between victims of sexual abuse and physical abuse in Israeli
women. To date, most research of abuse has focused on sexual abuse and physical
abuse as one unit, and many similarities have been found (Franko & Keel, 2006; Ullman
& Brecklin, 2003). However, several studies have been conducted that examine the
differential effects of each form of abuse. These studies revealed that sexual abuse is
perceived as having more severe repercussions than physical abuse (Anne, Nayak, Korcha,
& Greenfield, 2011). We hypothesized that victims of sexual abuse suffer more severe
injury to body experience (body image, body attitudes, body feelings and behaviors, and
body-image aberrations) than victims of physical abuse.
Abuse of women and children is a complex and multifaceted phenomenon as reflected
through its many diverse definitions. Physical abuse may include beating, slapping, kick-
ing, burns, threats with a weapon, and destruction of a loved object or pet (Straus, 1988).
In contrast, sexual abuse may include rape, forced intercourse, attempted rape, unwanted
sexual acts that do not include penetration, threat of bodily harm in response to refusing
sex (Straus, 1988). Physical and sexual abuse are usually committed by a family member or
person familiar to the victim (Korman, 2000). Sexual abuse committed by a family member,
or incest, is one of the most traumatizing forms of abuse of children who are at the mercy
of their known attackers (MacKinnon & James, 1992). Physical abuse of women is usually
referred to as battering, but some researchers only use the term in cases of repeated violent
acts. A review of relevant literature in Israel and in other countries shows that at least 7% of
women have a history of sexual abuse (Korman, 2000; Pereda, Guilera, Forns, & Gomez-
Benito, 2009), whereas physical violence is directed at about 10% (Lown &Vega, 2001).
The few studies published in Israel suggest that the prevalence of sexual and physical abuse
is similar to other Western countries (Schein et al., 2000; Tzionit & Kedman, 2001).
Physical and sexual abuse deeply affects the physical and mental health of victims. The
research and clinical literatures demonstrate that such abuse is often linked to a higher pro-
pensity for suicide attempts and self-inflicted damage (Etzel, 2006), eating disorders (Franko
& Keel, 2006; Treuer, Koperdak, Rozsa, & Furedi, 2005), addictive drug use (Segal, 2001;
Somer, 2003; Zickler, 2002), and somatic disorders (Ullman & Brecklin, 2003).
In addition, studies have shown that women who have undergone physical or sexual
abuse have more severe symptoms of depression (Csoboth, Birkas, & Gyorgy, 2005), more
dissociative symptoms (Somer, 2003; Sta & Elaine, 2005) and signs of PTSD (Filipas &
Ullman, 2006; Sharhabani-Arzy, Amir, Kotler, & Liran, 2003), as well as negative body
image and low self-esteem (Eubanks, Kenkel & Gardner, 2006); and more borderline
personality disorders (Lobbestael, Arntz, & Bernstein, 2010) than women with no history
of abuse. Also, it has been found that victims of physical or sexual abuse have difficulty
in establishing social ties (McCaw, Golding, Farley, & Minkoff, 2007), problems in sexual
function (Steel & Herlitz, 2005; Wilson, 2004), and often suffer from repeat victimization
(Briere, 2004; Whitfield, Anda, Dube, & Felitti, 2003).
Several studies have been conducted that examine the differential effects of each
form of abuse. These studies have found that women with history of sexual abuse have
significantly more posttraumatic symptoms (Amstadter & Vernon, 2008); more unex-
plained medical symptoms; and more symptoms of anxiety, depression, substance depen-
dence, and suicide attempts than women who have suffered physical abuse (Anne et al.,
2011; Fergusson, Boden, & Horwood, 2008; Techakasem & Kolkijkovin, 2001).
Sexual and physical abuse often occur in various phases during victims’ lifetimes and
together cause more trauma than just one form of abuse (Bonomi, Cannon, Anderson,
Rivara, & Thompson, 2008). These victims show higher propensity to drug use, more
suicide attempts, and a greater feeling of helplessness in their relationships (Wingood,
Diclemente, & Raj, 2000, as cited in Tzionit & Kedman, 2001) and more severe PTSD
symptoms (Hetzel & McCanne, 2005) than women who suffered physical abuse only.
Therefore, one should refer to sexual abuse, physical abuse, and both sexual and physical
abuse as separate phenomena, each with its nature and severity. Thus, this study examines the
differential effect of each kind of abuse on the overall experience of body, including body image,
body experiences, attitudes, feelings, and behaviors toward the body and body-image aberrations.
There is evidence that sexual and physical abuse cause severe damage to women’s bod-
ies and consequently to the way they relate to their bodies (Entrenas-Yepez, 2000; Treuer
et al., 2005). Body image is defined as a set of mental representations of the body that
reflect the general perceptions, emotions, expectations, cognitions, and behaviors related
to the body (Cash, 2004; Lebowitz, 2010; Schilder, 1935).
Straus (1988) describes the fundamental experience of mineness where the body is per-
ceived with a sense of ownership, acquired in early development and is based on physical
experiences and a clear definition of boundaries between what belongs to me opposed to
what belongs to others. It can be marred by pain and physical injury where people often
react by feeling alienated from their own bodies (Moss, 1989).
Body Image and Abuse 261
METHOD
Participants
Groups of women who suffered sexual abuse and physical abuse were selected using
nonprobability sampling of the target sample. This decision was taken because of the
difficulties in reaching this target population, which typically suffer severe emotional
trauma in all intimate, taboo matters as well as the difficulty in persuading them to
participate in the study. Relevant research literature indeed includes circumstances where
this method of nonrandomized selection is appropriate, such as cases where the target
population is very specific and difficult to sample (Patton, 1990).
In total, 98 women participated in this study, 76 of whom met the criteria determined by
the researchers, including a history of long-term and continuous abuse. Other 11 women
(10.9%) were not included in the final sample because they did not meet the study criteria
examining only those victims of long-term and continuous abuse. The four study groups
consisted of (a) 28 women who suffered both sexual and physical abuse, (b) 25 women
who suffered sexual abuse only, (c) 23 women who suffered physical abuse only, and
(d) 22 women with no history of any abuse who served as the control group. All of the
women were adults more than the age of 18 years (M 5 32.68, SD 5 10.88), with 89 of
them (90.8%) being native-born Israelis and only 9 (9.2%) are nonnatives.
To compare the categorical demographic variables (marital status and employment), x2
analyses were conducted. In addition, to compare successive demographic variables (age
and education), one-way ANOVA analyses were conducted. The results of these analyses
are presented in Table 1 and Table 2.
Marital status
Single N 10 16 9 12
% 45.5 64.0 39.1 42.9
Married N 11 7 9 6
% 50.0 28.0 39.1 21.4
Divorced N 1 2 5 10
% 4.5 8.0 21.7 35.7
Employment
Not working N 5 8 9 12
% 22.7 32.0 39.1 42.8
Part-time N 9 7 5 9
% 40.9 28.0 21.7 32.1
Full-time N 8 10 9 7
% 36.4 40.0 39.1 5.0
Body Image and Abuse 263
TABLE 2. Means (M), Standard Deviation (SD), and F of Age and Education
According to Group Distribution
Groups
Sexual &
Measurements Control Sexual Physical Physical F(3, 94)
The results of x2 analysis comparing the four groups showed a significant difference
only in reference to marital status (x2[6] 5 13.8, p , .05). As Table 1 indicates, the group
of both sexual and physical abuse consisted of more divorced women than the other
groups. In terms of employment, the distribution was quite even among women working
full-time, part-time, or not working.
As seen in Table 2, there is a significant difference between groups regarding the age
variable. When a further analysis (Scheffé) was conducted to determine the source of
these variations, results showed a significant difference between the control group and the
physical abuse group in terms of age variable with victims of physical abuse being older.
In contrast, no significant difference was found between the various groups in education
(the general mean was approximately 14 years of education).
Instruments
Personal Information Questionnaire (Demographic Details). This questionnaire included
age, ethnicity, education, employment, religion, marital status, and information about
which kind of abuse the women experienced over their lifetime: sexual abuse (yes/no) and
physical abuse (yes/no); and according to this information, the women were classified into
the four study groups. There was also a question about whether the abuse was a one-time
act or was long-term and continuous.
The Body Image Aberration Scale (Chapman, Chapman, & Raulin, 1978). This ques-
tionnaire addressed the experiential-sensory factor (or affect) of body image. It included
28 items that asked whether the sentence was relevant to the participant on a dichotomous
scale (true/false). The entries described body image aberrations, including unclear body
boundaries, feeling alienated from certain body parts, and others. The final score was
calculated by the total number of answers that testify to body image aberrations the par-
ticipants reported as relevant to them. A higher score meant that the participant had more
negative and distorted body experiences. The internal consistency of the questionnaire in
different populations ranged between a 5 0.88–0.94. When the questionnaire was trans-
lated to Hebrew, its internal consistency scored a 5 0.89 (Shani-Sela, 2000), and in this
study, internal consistency was also found at a 5 0.89.
Questionnaire of Body Sensitivity and Control (Shani-Sela, 2000). The purpose of
this questionnaire was to examine body sensitivity and control. It included 18 items on
a 1–5 scale (1 5 disagree completely; 5 5 agree very much) that were divided into two
groups: 9 items for assessing sensitivity to body clues and 9 items for assessing body
264 Kremer et al.
control. For each group of items, the calculated score was the average score of all items
within that group, indicating that a higher score in each meant more damage in sensitivity
to body clues and more damage to sense of body control. The internal consistency of the
questionnaire found in previous studies for the section assessing sensitivity to body clues
was a5 0.67 and for the section of body control was a 5 0.72 (Shani-Sela, 2000). In this
study, correlation between the two questionnaire sections was high (r 5 .70). Therefore,
the general score was based on an average of assessments of all the sections in the ques-
tionnaire. General reliability in this study was a 5 0.89.
Body Investment Scale (Orbach, 1994; Orbach & Mikulincer, 1998). This question-
naire addressed the attitudinal-behavioral component of body image, and it assessed the
measure of emotional investment in body and body experience. The short version of
the questionnaire (Orbach & Mikulincer, 1998) included 24 items rated on a 1–5 scale
(1 5 disagree completely; 5 5 agree very much) divided into four factors. Only the body
maintenance and protection factor was used in this study and it included six items. The
final score was calculated as the average score of all items. A high score meant greater
body maintenance and protection. Internal consistency of the questionnaire in body main-
tenance and protection found in previous studies was a 5 0.92 (Orbach & Mikulincer,
1998; Shani-Sela, 2000). Internal consistency of the body maintenance and protection
factor in this study was a 5 0.72.
A Pearson correlation test was conducted on the three body image measures to test if
there was significant overlap in what these scales measure. A high and significant correla-
tion was found between body image aberrations and body sensitivity and control (r 5 .71,
p , .001). In addition, significant negative correlations (although low) were found between
body sensitivity and control and body maintenance and protection (r 5 2.42, p , .001); and
between body image aberrations and body maintenance and rotection (r 5 2.45, p , .001).
Because these values did not reach the level of multicollinearity, the decision was made to
use all the questionnaires.
Procedure
We received the approval of Helsinki Committee of the University for the research proposal
including the participants, instruments, and the procedure before starting to recruit the
participants. Most of the women who participated in the study answered advertisements
published in university campuses and in various magazines. A very small number of women
were referred by Rape Crisis centers and Family Violence Assistance centers because of
the nominal cooperation on their part. The control group comprises a random selection of
community members (by publishing advertisements in various universities and through
acquaintances that passed out questionnaires to people from their workplaces). The partici-
pants who were willing to be part of the study contacted the study researcher and received
instructions on how they could fill in the questionnaires on their own. After completion of
the questionnaires, they sent them back by post in a return envelope that was included in the
questionnaire package. The members of the control group received their questionnaires from
the researcher. Like the members of the study group, they completed the questionnaires in
their home or workplaces and then sent them by post in the supplied return envelope.
The first page of the questionnaire contained a short explanation about the purpose
of the study, and a consent form to sign. We noted both in the opening page of the
questionnaire and verbally in the telephone that the researchers are available for them
for any problem. In addition, telephone numbers of four emergency centers that could
Body Image and Abuse 265
be available for them in a case of a stress were attached. The percentage of returned
questionnaires was around 90%. None of the participants was compensated for the time
devoted to the study.
RESULTS
To examine the differences between the measures of body image of the various study
groups, a 2 3 2 multivariate analysis of variance (MANOVA) was conducted. The indepen-
dent variables were sexual abuse (yes/no) and physical abuse (yes/no), and the dependent
variables were body image aberrations, body sensitivity and control, and body maintenance
and protection. Furthermore, to clarify possible interactions, simple effects tests were con-
ducted. Finally, to examine the unique contribution of each of the independent variables to
the explanation of body image variance, a hierarchical regression was conducted.
TABLE 3. Means (M), Standard Deviation (SD), F, and h2 Values of Body Image
Measurements Among Women Who Have/Have Not Suffered Sexual Abuse
Sexual Abuse
No Yes
Measurements M SD M SD F(1, 94) h2
TABLE 4. Means (M), Standard Deviation (SD), F and h2 Values of Body Image
Measurements Among Women Who Have/Have Not Suffered Physical Values
Physical Abuse
No Yes
Measurements M SD M SD F(1, 94) h2
physical abuse and those who did not in body sensitivity and control and in body main-
tenance and protection. The means and standard deviations of various bodily attitude
measurements and the results of the different analyses that were conducted for each factor
are presented in Table 4.
As seen in Table 4, variance analysis of each individual measurement revealed signifi-
cant differences in body maintenance and protection and more injury to body sensitivity
and control. The calculation of averages presented in Table 4 revealed that women who
were victims of physical abuse showed lower scores of body maintenance and protection
and higher scores of injury to sensitivity and control of the body in comparison to women
with no history of physical abuse.
Furthermore, a comparison of various body parameters of h2 in women who suffered
sexual abuse versus women who suffered physical abuse revealed a significant difference
in body maintenance and protection so that women who suffered sexual abuse demon-
strated less body maintenance and protection than women who suffered physical abuse.
Moreover, significant differences were found between women who suffered sexual abuse
and women who suffered physical abuse in injury to sensitivity and control of the body
scores: Victims of sexual abuse demonstrated more injury to body sensitivity and control
than victims of physical abuse. In addition, it was clear that in body image aberrations,
only women who suffered sexual abuse have significant body image aberrations.
The MANOVA analyses also revealed a significant interaction of sexual 3 physical
abuse (F[3, 92] 5 5.33, p , .01, h2 5 .15). Variance analysis of each individual measure-
ment revealed significant interaction only in the body maintenance and protection factor
(F[1, 94] 5 8.78, p , .01, h2 5 .09).
Among victims of sexual abuse, there is no significant difference between those who
suffered only sexual abuse (M 5 3.580, SD 5 0.63) and those who suffered both sexual
and physical abuse (M 5 3.696, SD 5 0.79). Conversely, women who were not victims of
sexual abuse (i.e., women who suffered only physical abuse) scored lower in body main-
tenance and protection (M 5 3.696, SD 5 0.56) than women with no history of physical
abuse (M 5 4.326, SD 5 0.37). Simple effects analyses that were conducted separately for
victims of sexual abuse versus women who did not suffer sexual abuse, while comparing
victims of physical abuse and women who did not suffer physical abuse, revealed a
significant difference among women who did not suffer sexual abuse (F[1, 43] 5 19.51,
Body Image and Abuse 267
p , .001, h2 5 .312), but no significant difference among women who were victims of
sexual abuse (F[1, 51) 5 .35, p . .05).
coefficient of interaction is higher than other regression coefficients; that is, interaction
between sexual abuse and physical abuse provides the greatest contribution to explain-
ing variance in body maintenance and protection. Beta coefficients of abuse are positive,
indicating that women who were victims of sexual and/or physical abuse show less body
maintenance and protection than women with no history of abuse.
It has been found that the interaction of sexual 3 physical abuse corresponds to the
interaction found in the variance analysis. Among victims of sexual abuse, there is no
significant difference in body maintenance and protection between those that suffered only
sexual abuse (M 5 3.58, SD 5 0.63) and those that suffered both sexual and physical abuse
(M5 3.696, SD 5 0.79). Conversely, women who were not victims of sexual abuse (i.e.,
women who suffered only physical abuse) scored lower in body maintenance and protec-
tion (M 5 3.696, SD 5 0.56) than women with no history of physical abuse (M 5 4.326,
SD 5 0.37). The data show that women with no history of abuse (sexual and/or physical)
score higher in body maintenance and protection than women who have been abused. One
should note that simple effects analyses conducted separately for victims of sexual abuse
versus women who did not suffer sexual abuse, while comparing victims of physical abuse
and women who did not suffer physical abuse, revealed a significant difference among
Body Image and Abuse 269
women who did not suffer sexual abuse (F[1, 43] 5 19.51, p , .001, h2 5 .312), but no
significant difference was found among victims of sexual abuse (F[1, 51] 5 .35, p . .005).
In general, it has been found that abuse measurements contribute 22% to explaining vari-
ance in body maintenance and protection.
The third dependent variable is body image aberrations. In the first stage, demographic
variables were included and it has been found that demographic variables contribute 13%
to explaining variance in body image aberrations. In the second stage, abuse variables
were included and a significant contribution was found in the measurements of sexual and
physical abuse. Clearly, beta coefficients of sexual abuse are higher than other regression
coefficients, that is, sexual abuse has a greater contribution in explaining variance in body
image aberrations. Beta coefficients of abuse measurements are negative, indicating that
victims of sexual or physical abuse have more body image aberrations than women with
no history of abuse. In general, it has been found that abuse variables contribute 17% to
explaining variance in body image aberrations.
DISCUSSION
This study indicates that sexual abuse and physical abuse have a differential impact on vic-
tims’ perception of their body and their attitude toward it. Women who experienced physical
abuse will suffer injury to various aspects of bodily attitude because during the assault, the
body was attacked, battered, and beaten. In addition, physical abuse lessens their sense of
ownership over their body and their body boundaries because their body was used as a punch-
ing bag by another. This objectification of a woman’s body can damage body maintenance
and protection mechanisms and concern over body functions. Women who experienced
sexual abuse also suffer similar damage in various aspects of bodily attitude. Nevertheless,
in contrast to physical abuse, which may lead to external injury, sexual abuse may lead to
both internal and external injury that may yield more severe injury in various aspects of a
woman’s bodily attitude. Indeed, the findings of this study confirmed this hypothesis.
Somer (2004) claims that “the inherently negative attitudes towards emotional and
physical abuse are obvious. In contrast, sex is an inherently appetitive and rewarding
experience” (p. 1). Although sexual abuse may include moments of enjoyment, hatred
toward one’s own body increases, the body is perceived as traitorous and unreliable, and
so the desire to hurt it or expose it to danger also increases (Walsh & Rosen, 1988). These
feelings may exacerbate the body image disorders that result from sexual abuse. Further
studies could examine this supposition that women who suffer sexual abuse may at times
also experience some measure of physical pleasure in reaction to sexual touch.
No significant difference in bodily attitudes between women who suffered sexual abuse
and women who suffered both sexual and physical abuse were found. This finding is in
line with the findings of previous studies (Karlin, 1999; Waldinger, Swett, Frank, & Miller,
1994) that have shown that sexual abuse has a higher significant impact on the mental and
physical health of women than physical abuse alone.
Likewise, Straus (1988) describes another fundamental experience in relation to one’s body
in a sense of mineness: A sense of ownership over one’s own body and clear body boundaries.
Because sexual abuse includes both internal and external assault of the body, there is a con-
stant sensation of external invasiveness into the internal spaces of the body, something that
could prove damaging to the feeling of clear body boundaries. Indeed, as found in this study,
only victims of sexual abuse have more body image aberrations that include an undermining
of their sense of ownership over their bodies and unclear body boundaries.
270 Kremer et al.
Defining the two forms of abuse as separate phenomena as implemented in this study
paves the way to a new research approach. Further studies should examine the specific
kind of injury caused by each form of abuse rather than addressing them together.
The findings of this study also have implications for treatment of both forms of abuse.
This study maintains that as both forms of abuse produce common and individual symp-
toms in the victims, then the clear classification of the repercussions could help focus
treatment in the particular characteristics of each injury and the specific symptoms unique
to each group (in line with Briere & Jordan, 2004).
The findings of this study show that women who suffered sexual abuse experienced more
severe injury to body image and body experience than women who were victims of physi-
cal abuse. Thus, when treating victims of sexual abuse, one of the key issues that should
be addressed is damage to bodily attitude. Victims of sexual abuse demonstrated less body
maintenance and protection, that is, their attitude toward their bodies was less positive,
they took less care of their bodies, and they expose themselves to danger more frequently.
Moreover, victims of sexual abuse suffered more injury to their sense of body control and
were less attentive to body clues. Lastly, these women had more negative and distorted physi-
cal sensations and a feeling that their body boundaries were unclear to them.
In view of all this, it is clear that treatment of victims of sexual abuse should help
women to cope with the extensive damage to body image that is the consequence of this
abuse. Treatment should help women maintain and nurture their bodies, to cope with the
rejection they feel regarding it, to deal with the distorted body perceptions they have, and
help them restore the sense of ownership and control they should have over their bodies.
One of the possible approaches for therapy is Body Focused Intervention (Asselstine,
2000), which associates between sensor feelings that have remained in memory and the
internalization of body–soul relationships. This procedure may lead clients to an integra-
tive relation to their body. Other therapeutic approaches (Price, 2004; Segal, Williams, &
Teasdale, 2002) may be relevant to these cases as well.
There are only few studies in Israel that have examined the psychological implications
of physical and sexual abuse. Furthermore, this is one of the few studies on this topic
that was conducted for the aim of revealing the differences between bodily attitudes in
women abused sexually rather than physically. However, there are number of method-
ological remarks that should be taken into consideration. Future studies should compare
the groups not only according to the different forms of abuse but also according to the
differences in the severity and duration of the abuse. Also, to expand the generalizability
of the findings, more representative segment of this population of abused women should
be recruited. Future study should classify the groups not only by form of abuse but also
by whether the women received therapy; and further examine if women who received
therapy show fewer injuries in various aspects of body image in comparison to women
who did not receive therapy.
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