Sexual Behavior and Concerns in a Sample of Elderly, Former Indentured Swiss Child Laborers

Zurich Open Repository and Archive University of Zurich Main Library Strickhofstrasse 39 CH-8057 Zurich www.zora.uzh.ch

Year: 2015

Rechsteiner, Karin ; Burri, Andrea ; Maercker, Andreas

Abstract: Introduction Past research suggests a link between post-traumatic stress disorder (PTSD) and an increased risk for sexual problems. However, there is still no clear picture whether these higher rates are related to trauma exposure or to PTSD itself. Aim The aim of the present study was to complement existing knowledge on the relative impact of trauma and PTSD on sexuality in later life, considering different aspects of trauma exposure on both men and women. Methods The study was conducted ona unique population sample of former Swiss indentured child laborers (55 men, Mage 78, age range 60–95 years) who have repeatedly experienced a variety of severe childhood traumas. Main Outcome Measures Sexual outcomes were measured using two scales from the Trauma Symptom Inventory—Dysfunctional Sexual Behavior (DSB) and Sexual Concerns (SC). PTSD symptoms and trauma were assessed with the Short Screening Scale for PTSD and the Composite International Diagnostic Interview, respectively. Results Twenty-two individuals showed PTSD symptoms, and 53 reported having experienced childhood trauma. Significant differences between men and women were reported for DSB and SC. Men reported a significantly higher prevalence of both SC and DSB compared with women. Conclusions This isthevery first study investigating DSB and SC in a sample of older adults exposed to similar traumatic experiences and settings. However, some study limitations need to be considered such as the small sample size. Additional studies are needed to further explore the relative role of traumatization and PTSD on sexual behavior and well-being, especially to improve sexual therapy for patients who experience trauma.

DOI: https://doi.org/10.1002/sm2.84

Posted at the Zurich Open Repository and Archive, University of Zurich ZORA URL: https://doi.org/10.5167/uzh-115778 Journal Article Published Version

The following work is licensed under a Creative Commons: Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) License.

Originally published at: Rechsteiner, Karin; Burri, Andrea; Maercker, Andreas (2015). Sexual Behavior and Concerns in a Sample of Elderly, Former Indentured Swiss Child Laborers. Sexual Medicine, 3(4):311-320. DOI: https://doi.org/10.1002/sm2.84 ORIGINAL RESEARCH—PSYCHOLOGY

Sexual Behavior and Concerns in a Sample of Elderly, Former Indentured Swiss Child Laborers

Karin Rechsteiner, MSc, Andrea Burri, PhD, and Andreas Maercker, PhD, MD University of Zurich—Department of Psychology, Zurich, Switzerland

DOI: 10.1002/sm2.84

ABSTRACT

Introduction. Past research suggests a link between post-traumatic stress disorder (PTSD) and an increased risk for sexual problems. However, there is still no clear picture whether these higher rates are related to trauma exposure or to PTSD itself. Aim. The aim of the present study was to complement existing knowledge on the relative impact of trauma and PTSD on sexuality in later life, considering different aspects of trauma exposure on both men and women. Methods. The study was conducted on a unique population sample of former Swiss indentured child laborers (55

men, Mage 78, age range 60–95 years) who have repeatedly experienced a variety of severe childhood traumas. Main Outcome Measures. Sexual outcomes were measured using two scales from the Trauma Symptom Inventory— Dysfunctional Sexual Behavior (DSB) and Sexual Concerns (SC). PTSD symptoms and trauma were assessed with the Short Screening Scale for PTSD and the Composite International Diagnostic Interview, respectively. Results. Twenty-two individuals showed PTSD symptoms, and 53 reported having experienced childhood trauma. Significant differences between men and women were reported for DSB and SC. Men reported a significantly higher prevalence of both SC and DSB compared with women. Conclusions. This is the very first study investigating DSB and SC in a sample of older adults exposed to similar traumatic experiences and settings. However, some study limitations need to be considered such as the small sample size. Additional studies are needed to further explore the relative role of traumatization and PTSD on sexual behavior and well-being, especially to improve sexual therapy for patients who experience trauma. Rechsteiner K, Burri A, and Maercker A. Sexual behavior and concerns in a sample of elderly, former indentured Swiss child laborers. Sex Med 2015;3:311–320. Key Words. Sexual Behavior; Sexual Concerns; Post-Traumatic Stress Disorder; Trauma; Old Age

Introduction health, and hence impacts on health-related quality of life [1,2]. Recent studies have suggested ost-traumatic stress disorder (PTSD) is a psy- that the presence of PTSD is also associated with P chiatric disorder describing the long-lasting increased rates of sexual problems in both men and symptoms that can occur after exposure to women [3–5]. extremely stressful life events. It has been well The majority of studies investigating the rela- documented that PTSD signiﬁcantly affects emo- tionship between traumatization, PTSD, and tional, social–interpersonal, as well as physical sexual problems focus on male combat veterans

© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:311–320 on behalf of International Society for Sexual Medicine. This is an open access article under the terms of the Creative Commons Attribution-NonCommercial License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited and is not used for commercial purposes. 312 Rechsteiner et al. and female rape victims. Results from these studies Aims have consistently suggested that combat veterans The aim of the present study was to complement with PTSD experience a higher rate of sexual dys- knowledge on the effects of previous abusive function than those without PTSD and that rates experience on sexual behavior and function in of sexual problems of veterans exceed rates of later life, using a population sample of former similar problems found in community samples. female and male Swiss indentured child laborers Such sexual difficulties mainly include premature who have repeatedly experienced a variety of ejaculation and failure to achieve or maintain erec- severe childhood traumas (CTs). More specifi- tion, although sexual disinterest and orgasm diffi- cally, the aims were: first, to present descriptive culties have also been reported [3,6,7]. Research data regarding the presence of sexual problems on women with PTSD remains comparably scarce, and concerns; second, to explore descriptive dif- but findings also highlight the serious effects of ferences between men and women in terms of PTSD morbidity on women’s sexual satisfaction trauma exposure, PTSD, and demographic and and function. Exploration of the impact of trauma sexual characteristics as well as to examine the alone (without PTSD) on women has mainly associations between these variables; third, to focused on sexual assault and found that assault investigate whether the specific type and category survivors have an increased likelihood of risky (i.e., interpersonal vs. accidental; see Methods sexual behavior and problems such as anorgasmia, section), as well as the number of trauma (i.e., sexual anhedonia, and multiple sex partners [8,9]. cumulative trauma), are associated with the vari- Research has further demonstrated significant ance in sexual symptoms (i.e., does sexual abuse associations between previous experience of impact more on sexual behavior compared with, trauma and sexual problems independent of PTSD e.g., physical abuse); and fourth, to explore differ- diagnosis and symptoms [10,11]. While some ences in sexual outcomes and continuous, as well study findings suggest that the specific form of as categorical, measures of PTSD symptoms. In abuse is irrelevant to the development of sexual this sense, we postulated the following hypoth- problems, other studies highlight that especially eses: First, older men would report higher rates of sexual trauma—and childhood sexual abuse in sexual concerns and dysfunctional sexual behavior particular—seems to be linked to the impairment compared with older women. Second, trauma- of sexual functioning in later life [11,12]. In addi- tized individuals with PTSD symptoms report tion, research findings have also highlighted the higher rates of sexual concerns and dysfunctional association between accumulated exposure of dif- sexual behavior compared with traumatized indi- ferent types of traumatic events (i.e., cumulative viduals without PTSD symptoms. Third, indi- trauma) and disease-specific symptom severity in viduals with CT exposure report higher rates of a number of areas, such as anxiety, depression, sexual concerns and dysfunctional sexual behavior anger, and somatic complaints [13–16]. It is very compared with individuals with trauma exposure likely that such cumulative effects resulting from occurring in adulthood. repetitive trauma exposure can also be observed on sexual parameters and health. Although previous studies have demonstrated Methods the serious effects of PTSD and trauma on men and women’s sexual behavior, research in this particular This study constitutes a substudy within a bigger area—most of all in both women and men and in project [17]. The main study started as an explor- older adults—remains scarce. In particular, the role ative longitudinal study consisting of two mea- of trauma-type specificity (e.g., emotional neglect surement points (at an 18-month interval) vs. physical abuse vs. sexual abuse), as well as the assessing traumatization, PTSD symptoms, and potential cumulative effects of multiple traumas on long-term effects on a variety of aspects (e.g., sexuality, and the relative role of trauma exposure cognitive function, bonding, and development vs. PTSD have been fairly ignored so far. More- and prevalence of mental disorders). Data assess- over, epidemiologic studies investigating sexuality ment for the first measurement point (T1) started in older adults are next to inexistent, and only little in May 2010 and was completed in April 2012. research has explored the effects of traumatization Collection of psychometric data for the second and PTSD on individuals’ sexual behaviour in non- measurement point (T2) started in summer 2012 combat veteran men or in men and women with and is still ongoing. Data used in this study were similar trauma experiences. taken from T1 only.

Sex Med 2015;3:311–320 © 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. on behalf of International Society for Sexual Medicine. Trauma, PTSD, and Sexual Behavior and Concerns 313

Participants functioning and concerns [19,20]. The TSI is a The study sample was drawn from an initial 100-item measure of psychological sequelae of sample of 141 former Swiss indentured child traumatic events. Each item describes a symptom, laborers (i.e., “Verdingkinder”). During the 1950s, which is rated for frequency of occurrence in the these children were separated from their parents past 6 months (0 = never,3= very often). The TSI (usually poor or single mothers) by the Swiss includes three validity scales (Response Level, authorities and sent to work on farms. Historic Atypical Response, and Inconsistent Response), studies have shown that many of these children which assess the tendency of respondents to suffered extreme forms of abusive experiences as endorse items with low base rates of endorsement they were regularly beaten, emotionally and even or to respond inconsistently. In addition to the sexually abused [17,18]. three validity scales, the TSI contains 10 clinical scales, including measures of dysfunctional sexual Inclusion and Exclusion Criteria behavior and sexual concerns. The Dysfunctional To be included in the study, the following criteria Sexual Behavior (DSB) scale consists of nine items had to be met: (Swiss)-German speaking; a (e.g., “Having sex to keep from feeling lonely or minimum age of 60 years; at least one experienced sad”) and assesses sexual behaviors that are self- period of child slavery; reported at least one trau- defeating or maladaptive because of an indiscrimi- matic experience (see Methods section). Partici- nate quality, potential for self-harm, or use for pants were recruited via advertisements in local nonsexual purposes. The Sexual Concerns (SC) and national newspapers and magazines, and via scale also consists of nine items (e.g., “Bad specific “Verdingkind”-associations. All partici- thoughts or feelings during sex”) and assesses pants provided informed consent and stated their self-reported sexual distress, including sexual dis- willingness to participate in this study. satisfaction, sexual functioning problems, and unwanted sexual thoughts or feelings [19,21]. Procedure Neither scale includes any items explicitly assess- After providing written informed consent, partici- ing number of sex partners or frequency of sexual pants participated in a 2- to 4-hour interview and behavior. were asked to fill in a battery of questionnaires The TSI has been widely validated and trans- assessing information related to PTSD, trauma, lated into a number of languages. The psychomet- cognitive ability, and mental and physical health. ric properties have shown to be very good, with The interview was conducted by instructed internal consistency for the clinical scales showing research assistants and/or doctoral students, either alphas ranging from 0.74 to 0.91 [19]. The author at the Psychology Institute of the University of further reports evidence of discriminant validity, Zurich or alternatively at the participants’ homes. with patients with a trauma history scoring signifi- Participants were not given any compensation for cantly higher than nontraumatized patients. Inter- participation. nal consistency as assessed using Cronbach’s alpha was α=0.83 for SC and α=0.84 for DSB in this Ethical Review study, which corresponds to the mean alphas of The study was conducted following the ethical 0.86, 0.87, 0.84, and 0.84 found in general popu- standards of the German and Swiss psychological lation, clinical, university, and military samples, associations. Formal approval of the project was respectively [19]. obtained by the Ethics Committee of the Canton of Zurich. Trauma Exposure (Childhood Adversity and Traumatic Life Experiences) Main Outcome Measures Potentially traumatic experiences were assessed with the Short Version of the Childhood Trauma Socio-Demographic Information Questionnaire [22,23] and the trauma list of the Information regarding socio-demographic status Composite International Diagnostic Interview of the participants was assessed with self- (CIDI) [24]. The CTQ is a self-report inventory constructed questions. that provides brief, reliable, and valid screening for histories of abuse and neglect. In addition, the Sexual Behavior and Concerns CIDI’s list of traumatic events (11 events including Two scales from the Trauma Symptom Inventory direct combat experience in a war; life-threatening (TSI) were used to assess the participants’ sexual accident; natural disaster; witnessed someone

© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:311–320 on behalf of International Society for Sexual Medicine. 314 Rechsteiner et al. being badly injured or killed; rape; sexual moles- Dissociation (DIS), and Impaired Self-Reference tation; serious physical attack or assault; threat- (ISR) [19]. ened with a weapon, held captive, or kidnapped; torture or terrorism; any other extremely stressful Depression or upsetting event; great shock because one of the Symptoms of depression were assessed using the events on the list happened to someone close) short 15-item version of the Geriatric Depression served as a guide to determine the most severe Scale (GDS), a self-report instrument specifically traumatizing life experience participants had gone designed to identify depression in older people through [25]. [30]. The questions are answered by “yes” or “no,” According to the information provided, the and this simplicity enables the scale to be used with traumatic events were categorized into CT (having ill or moderately cognitively impaired individuals occurred before the age of 18 years) and adulthood [31]. Scores greater than 4 indicate the presence of trauma (AT) and were further classified according depression, which can be classified as mild, mod- to the type of trauma (including sexual abuse, erate, or severe. Validation of the German version emotional abuse/neglect, physical abuse, self- of the GDS found the instrument to be a reliable experienced death threat, severe accident/illness, and valid screening instrument with an average witnessing a severe accident, losing a close item discrimination of 0.5, low inter-item correla- member of the family or reference person, and tion (r = 0.2), and a very high internal consistency other/not specified—e.g., imprisonment). (α=0.9) [32]. In the current study, GDS showed Traumatic events can additionally be subsumed adequate internal consistency and reliability into different types of trauma [26]. Maercker pro- (α=0.8). posed an orienting scheme that subsumes traumatic experience into two main categories: Statistical Analyses interpersonal vs. accidental traumas. While inter- Statistical analyses were conducted using stata personal traumas relate to sexual and physical (Version 10.0, 2008, StataCorp, College Station, assault, combat, violent assault and torture, acci- TX, USA). From the total of 141 participants with dental traumas include disasters and severe auto- available T1 data, analyses were conducted on a mobile accidents, for example. total of 96 individuals with complete data. Com- parative analyses revealed that the subsample did not differ in any of the socio-demographic or vari- PTSD ables relating to trauma, PTSD, or sexual behavior For the assessment of PTSD symptomatology, the and concerns compared with the full sample. Short Screening Scale (SSS) [27,28] was used. The For descriptive statistics, two-sample tests of seven-item SSS for PTSD is an empirically proportions to assess differences between gender derived instrument used to discriminate between on categorical and binary data were used. Because individuals with PTSD symptoms and healthy normality of the data could not be assumed given ones [27]. Five of the seven symptoms relate to the skewness of the distribution of the dependent the avoidance and numbing symptom clusters and variables (i.e., DSB and SC), Mann–Whitney tests two to the hyperarousal symptom cluster. Partici- were used to assess differences between men pants’ answers were rated on a four-point scale and women on the continuous variables. Correla- (0 = “never/only once” to 3 = “five times a week/ tions between the various dependent and inde- almost always”), and a total mean score was calcu- pendent variables were calculated using Pearson’s lated representing PTSD symptom severity. The correlation (for continuous variables) and point- authors of the SSS suggest a cutoff score of 4, biserial correlation (for continuous and binary which best balances the scale’s ability to detect variables). All tests were two-tailed. For all analy- patients with or without PTSD. The specific per- ses, a P value less than 0.05 was considered sta- formance characteristics of the SSS (including the tistically significant, unless stated otherwise. German version) have recently been investigated Bonferroni correction was used to account for in two studies and are considered very good multiple testing. [28,29]. Cronbach’s alpha of the scale in our study According to the information regarding the was acceptable with α=0.72. The psychological time that the trauma was experienced (CT vs. AT) impact of trauma was further measured using and the PTSD status (positive vs. negative), the following TSI scales: Anxious Arousal (AA), participants were assigned to four different groups: Anger/Irritability (AI), Intrusive Experiences (IE), CT/PTSD+ (n = 10), CT/PTSD− (n = 31),

AT/PTSD+ (n = 12), and AT/PTSD− (n = 43). women were reported for both TSI scales assess- Categorization to interpersonal vs. accidental ing sexual behavior and concerns (U = 398.00, trauma was done according to the nature of the z =−3.60, P < 0.001 and U = 365.00, z =−3.26, reported main traumatic event. By adding up the P =<0.001, respectively). In average, men scored number of reported trauma, a cumulative trauma higher than women in all single items of both the score was created. Because normality of the data SC and the DSB scales. Both genders presented could not be assumed given the low sample size in the highest mean scores for the SC item “not some of the groups, univariate Kruskal–Wallis being satisfied with your sex life.” Regarding the analyses (nonparametric test, equivalent to anova) DSB scale, while men presented the highest mean were calculated to compare the score differences score for the item “flirting” or “coming on” to between the four main groups for the continuous someone “to get attention,” women showed the sexuality-related variables. To control for the highest mean for the item “getting into trouble influence of depression and age as potential because of sex.” covariates on the sexual outcome variables, While physical violence, sexual abuse, and emo- Kruskal–Wallis tests were performed on covariate- tional abuse/neglect were the most prevalent adjusted residuals (i.e., GDS and age). Covariate- forms of experienced abuse in childhood (32.1%, adjusted residuals were obtained from the overall 20.8%, and 20.8%, respectively), the most regression line fit to the entire data set. frequently reported traumas in adulthood were “other” (25.6%), witnessing death/accident (20.9%), and death of a family member (16.3%). Results Physical or sexual violence was reported by 6.9% Table 1 shows the sample characteristics of the of the participants, and none listed emotional overall sample (N = 96) and by gender (n = 55 abuse/neglect as the most severe traumatic event. men, 57.3%). The age of the participants ranged There were no gender differences as to whether from 59 to 95 years (M = 77.57, SD = 6.29). Most the traumas were experienced during adulthood of them were married (41.7%), while most of the or during childhood. However, men and women women were widowed (39.0%). According to the differed significantly in the prevalence of sexual SSS (cutoff score of 4), 22 individuals (22.9%) abuse (χ2[1] = 5.11, P = 0.024) and physical abuse screened positively for PTSD symptoms, and no (χ2[1] = 0.97, P = 0.032), with men more fre- significant gender differences were detected in quently reporting previous physical abuse (25.9% terms of screening positively or negatively for vs. 15.0%) and women more frequently reporting PTSD. Significant differences between men and sexual abuse (5.6% vs. 27.5%).

Table 1 Sample characteristics of the overall sample and by gender

Overall (N = 96) Men (n = 55) Women (n = 41) Variables M SD Range M SD Range M SD Range P

Age 77.57 6.29 60–95 77.65 5.32 69–90 77.46 7.46 60–95 0.89 CUM 2.20 0.78 1–3 2.18 0.82 1–3 2.22 0.73 1–3 0.91 GDS 3.81 3.54 0–13 3.46 3.42 0–13 4.28 3.69 0–13 0.22 SC 3.32 4.82 0–23 4.33 3.48 0–20 1.87 4.52 0–23 <0.01 DSB 1.71 3.68 0–21 2.77 3.49 0–21 0.19 0.60 0–3 <0.01

Overall (N = 96) Men (n = 55) Women (n = 41)

Variables N% n%n % P

PTSD 22 22.9 13 23.6 9 22.0 0.85 CT 53 52.2 29 52.7 24 58.5 0.57 EA 11 11.7 4 7.4 7 17.5 0.14 PA 17 21.3 14 25.9 6 15.0 0.03 SA 11 14.9 3 5.6 11 27.5 0.02 Relationship status Single 6 6.3 3 5.5 3 7.3 0.70 Married 40 41.7 30 54.6 10 24.4 <0.01 Separated 24 25.0 12 21.8 12 29.3 0.40 Widowed 26 27.1 10 18.2 16 39.0 0.02

CUM = cumulative trauma; GDS = Geriatric Depression Scale; SC = sexual concerns; DSB = dysfunctional sexual behavior; CT = childhood trauma; EA = emotional abuse; PA = physical abuse; SA = sexual abuse.

Table 2 Correlations between the variables in the overall sample

Physical Sexual Emotional Interpersonal Accidental Cumulative Age GDS SC DSB PTSD CT abuse abuse abuse trauma trauma trauma SC −0.08 0.06 — 0.57*** 0.13 0.10 0.19* 0.17 −0.17 0.22* 0.01 0.17 DSB −0.12 −0.04 0.57*** — 0.01 0.12 0.00 0.05 −0.13 0.01 0.13 0.14

*P < 0.05, **P < 0.01, ***P < 0.001GDS = Geriatric Depression Scale; SC = sexual concerns; DSB = dysfunctional sexual behavior; CT = childhood trauma.

Statistically significant relationships could be 0.43). Significant associations could also be found observed between the two TSI domains DSB and between AI, DIS, and IE and DSB (rs ranging SC (r = 0.57, P < 0.001) and between SC and from 0.20 to 0.26) (Table 3). physical abuse (r = 0.19, P < 0.05) (Table 2). No Comparisons of the four PTSD/trauma groups associations between any other type of abusive did not show any significant differences across the experience with either SC or DSB could be groups (Table 4). However, results of the Kruskal– detected. Contrary to what was expected, the Wallis tests indicated substantial differences cumulative effect of trauma (i.e., higher number of between them regarding the sexual outcomes, traumas experienced) was not statistically signifi- although none reached conventional significance cant related to either DSB or SC. In a second step, level. Individuals reporting AT and PTSD symp- the different trauma types were assigned to either toms scored higher in both TSI scales tapping for the “interpersonal trauma” (e.g., sexual abuse) or sexual outcomes than individuals reporting CT the “accidental trauma” (e.g., witnessing a severe and PTSD symptoms. Nevertheless, and because accident) group. While there was no significant of the frequently reported impact of age and association between the two broad trauma catego- depression on sexual parameters, these variables ries with DSB, a significant relationship between were included as potential confounders in the SC and interpersonal trauma could be detected main analyses. (r = 0.22, P > 0.05) (Table 2). To further investigate whether individuals suf- Discussion fering from more psychological post-traumatic symptoms also reported more DSB and SC, the Tothe best of our knowledge, this is the first study correlations between the TSI psychological investigating the relative effects of trauma and symptom scales and the TSI sexuality scales were PTSD on sexual behavior in old age. To assess calculated. AA, AI, DIS, as well as IE all correlated sexual behavior, we administered the TSI subscales significantly with SC (rs ranging from 0.27 to “Sexual Concerns” and “Dysfunctional Sexual

Table 3 Correlations between psychological symptoms of trauma (as assessed by the TSI) and sexual behavior and concerns

Anxious arousal Anger irritability Intrusive experiences Dissociation Impaired self-reference

SC (n = 73) 0.27** 0.36*** 0.14 0.42*** 0.43*** DSB (n = 75) 0.07 0.20* 0.05 0.23* 0.26**

*P < 0.05, **P < 0.01, ***P < 0.001SC = sexual concerns; DSB = dysfunctional sexual behavior.

Table 4 Result of analysis of variance (Kruskal–Wallis test) for the means of the continuous variables across the four trauma/PTSD groups

CT/PTSD+ (n = 10) CT/PTSD− (n = 31) AT/PTSD+ (n = 12) AT/PTSD− (n = 43)

Variables M SD Range M SD Range M SD Range M SD Range H

Age 75.90 4.51 69–86 75.90 6.67 60–95 78.50 7.13 70–90 78.91 5.94 68–93 5.5 CUM 2.20 0.63 1–3 2.42 0.72 1–3 2.33 0.89 1–3 2.00 0.79 1–3 5.9 GDS 4.56 3.90 0–13 3.77 3.41 0–13 4.33 3.76 0–13 3.52 3.60 0–11 1.3 SC 2.22 2.91 0–7 3.41 4.61 0–15 6.67 8.82 0–23 2.64 3.57 0–14 1.4 DSB 0.60 1.08 0–3 1.18 2.26 0–8 2.60 6.54 0–21 2.12 3.81 0–14 0.7

CUM = cumulative trauma; GDS = Geriatric Depression Scale; SP = sexual problems (sum score SC + DSB); SC = sexual concerns; DSB = dysfunctional sexual behavior; CT = childhood trauma.

Table 5 Comparison of means and standard deviation of SC and DSB raw scores between studies for men

Current study Sample standardization Clinical sample Trauma ages Younger: ages Older: ages 55 and No trauma Trauma 60–95 (n = 55) 18–54 (n = 267) older (n = 158) (n = 29) (n = 37) Scale M SD M SD M SD M SD M SD SC 4.33 3.48 4.30 5.20 2.41 3.61 4.82 4.29 9.73 9.15 DSB 2.77 3.49 2.32 4.20 1.03 2.43 2.24 3.17 6.30 7.44

Sample Standardization [33]; Clinical Sample [20]. SC = sexual concerns; DSB = dysfunctional sexual behavior.

Behavior” capturing sexual dissatisfaction, as well in this study. On the other hand, when comparing as sexual behaviors that are dangerous, indiscrimi- individuals with and without trauma history nate, or used to achieve nonsexual gains [19]. Only without controlling for age, women reported even few studies have looked at the independent more SC and DSB than men [19]. The study con- effects of trauma and PTSD on men’s and ducted by Elliott [33] is the only study known to women’s sexuality, most of which have relied on have investigated SC and DSB specifically in an male combat veterans or focused on sexual dys- older sample. It illustrates how age is an important function [3–5,9,16]. Contrary to these studies, we factor relating to sexuality and that it should be used a sample of older men and women who included in the analyses. The same can be said for underwent similar severe and repetitive trauma gender differences. during childhood within the context of their In the present study, we found a significant period of “indentured child laboring.” In addition, gender difference in sexual concerns and sexual we assessed the specific effects of trauma type/ dysfunction, in that men were significantly more category, as well as the cumulative effects of repeti- distressed and reported more sexual dissatisfaction tive trauma exposure on sexual parameters and and more maladaptive sexual behavior compared further provided descriptive data of sexual con- with women. It seems that trauma exposure has cerns and dysfunctional sexual behavior in older more impairing effects on men’s sexual well-being, adults instead of reporting on sexual functioning. compared with women in old age. Alternatively, it The occurrence of SC and DSB was found to be is also likely that women consider sexuality or inti- relatively low in this study, considering that the macy less important in older age and/or that recall participants were former indentured child labor- bias is more present in women compared with men ers, individuals highly susceptible to having a [34]. Gender differences were more accentuated history of traumatic experiences. However, when for sexual concerns compared with dysfunctional comparing the means of SC and DSB of the par- sexual behavior. ticipants of this study to the means of older par- Although there is an extensive body of literature ticipants of another study, the low prevalence rate suggesting the tendency for sexual abuse alone to can be understood in this context (Tables 5 and 6). predict sexual symptoms (e.g., Briere et al. [13,20]), The means of SC and DSB found for men were only physical abuse was significantly associated twice as high compared with older men in the with sexual concerns in this study. None of the sample standardization of the TSI [33]. For other trauma exposure types (i.e., sexual or emo- women, the mean score of SC was similar, tional abuse) were associated with either SC or although the mean score of DSB was slightly lower DSB. These findings are in line with a recent

Table 6 Comparison of means and standard deviation of SC and DSB raw scores between studies for women

Current study Sample standardization Clinical sample

Trauma ages Younger: ages Older: ages 55 and No trauma Trauma 60–95 (n = 41) 18–54 (n = 291) older (n = 120) (n = 43) (n = 261) Scale M SD M SD M SD M SD M SD SC 1.87 4.52 4.06 5.27 1.71 3.52 5.54 6.24 10.57 2.68 DSB 0.19 0.60 2.29 3.94 0.68 1.47 2.81 4.54 4.64 5.88

Sample Standardization [33]; Clinical Sample [20]. SC = sexual concerns; DSB = dysfunctional sexual behavior.

© 2015 The Authors. Sexual Medicine published by Wiley Periodicals, Inc. Sex Med 2015;3:311–320 on behalf of International Society for Sexual Medicine. 318 Rechsteiner et al. epidemiologic study, which found a significant rela- Limitations tionship between previous experiences of any kind The results of this study should be considered of abuse and sexual impairment of various domains in light of several limitations. First, the current of women’s sexual functioning [10]. The study study is a substudy within a bigger project called further revealed that the specific form of abuse was “Former Indentured Children in Old Age” so that irrelevant to the development of sexual problems, the data were used for a secondary analysis. In this suggesting that different types of abuse—whether sense, the used measurements were not designed they are of emotional, sexual, or physical nature— to the answer the research questions of this study all have similar effects on one’s emotional regula- specifically. However, the TSI is a well-established tion and sexuality. This study also supports our questionnaire for the assessment of trauma corre- findings concerning the artificial categorization lates, including abnormal sexual symptoms [19]. of the various traumas into interpersonal vs. Future research should further assess other impor- accidental—interpersonal trauma was more signifi- tant factors investigating this relationship, such as cantly associated with SC compared with accidental sexual orientation and physical health. trauma. Further, no specific effects of cumulative Second, the results of this study cannot be gen- trauma on sexual behavior could be detected in the eralized to the overall population, as this sample is present study, but additional research including homogenous in terms of race, ethnicity, and socio- both men and women and assessing different types economic status. Besides, due to the uniqueness of of trauma events is needed. the recruited participants (former indentured child Overall, the results of this study support that laborers), the sample size was relatively small, par- neither time of the traumatic event nor screening ticularly when considering the group comparisons. positively for PTSD symptoms is an independent This may have led to restrictive statistical power risk factor or predictor for sexual problems. for some analyses. Nevertheless, the chi-squared However, group comparisons tentatively indicate approximation of the Kruskal–Wallis test has that individuals who screened positively for PTSD proven to be highly satisfactory also when samples symptoms and reported AT showed more SC and are small [36]. DSB compared with individuals without PTSD Third, the extrapolation of our study results to symptoms or reporting CT. Although this finding other populations might be limited due to the spe- did not reach statistical significance—possibly due cific sample characteristics of our former child to restricted sample size—the relative difference in laborer cohort, which represents an unusual scores between the two groups tentatively points subpopulation in terms of life histories and char- toward a different impact of time of trauma expo- acteristics. However, long-lasting traumatic expe- sure (childhood vs. adulthood) on sexual behavior. riences during childhood are prevalent even in These results are not in line with literature sug- more common community samples [37]. gesting that CT has more drastic effects on sexual Fourth, this study had access to limited data, function and concerns than AT [19]. However, not addressing the effects, for example, of rela- there is no study comparing the impact of child- tionship satisfaction, which may be an important hood vs. AT and PTSD symptoms. confounder when investigating sexual functioning In addition, there is a general paucity of data and concerns. Some of the participants did not regarding sexual functioning in cohorts of older respond to the sex-related questions, because adults. Although research has repeatedly shown they claimed that sexual activity was not a part of that sexual functioning decreases as a function of their lives anymore. The frequency of sexual rela- age, this does not seem to be true for all aspects of tionships was also not controlled for, which an individual’s sexuality, suggesting that age means that individuals in old age reporting no SC cannot be regarded a global risk factor for the and DSB at all may actually have an inactive sex development of sexual problems [10,35]. This life. would also explain why the TSI subscale of SC Fifth, it is not possible to exclude the fact that showed considerably more variation across partici- participants’ reports were affected by biases, as the pants compared with the DSB scale. It seems data collected relied on retrospective self-reports. that sexuality and intimacy remains important in The retrospective reports may have been affected later life—independent of physiologic sexual by recall bias, especially considering the presence functioning—and that high relationship qualities of cognitive impairment found in this sample. and preservation of sexual activity can significantly In addition, sexual problems have always been a contribute to sexual satisfaction. matter of shame, nondisclosure, and uneasiness

[38]. Thus, the sexual outcomes may have been tionship. Additional studies are needed to further affected by the openness of these elder partici- explore the role of trauma type and cumulative pants. However, we did not find evidence for such trauma exposure as well as the relative role of biases in our study, as the TSI includes three valid- traumatization and PTSD symptomatology in ity scales to help indicate invalid profiles and also sexuality. Clarifying whether the risk carrier is the control for social desirability bias. exposure to trauma or PTSD in itself may be Sixth, this was a cross-sectional study, and the essential in choosing the right treatment for sexual development of sexuality across the entire lifespan problems. However, sexuality should be part of the could therefore not be assessed. Several studies assessment and management of both trauma and indicate a gradual decline in sexual activity accord- PTSD therapy. General practitioners and psychia- ing to age, but it is not clear whether these changes trists should also be aware of the consequences are rather related to cohort effects or to the aging that trauma and/or PTSD can have on sexual process. There are only few longitudinal studies well-being. investigating the stability of sexual activity and interest, and these studies present mixed findings Acknowledgments [39,40]. Future research should further explore sexuality over time. Andrea Burri reports an Ambizione personal career fel- Last but not least, an important methodological lowship from the Swiss National Science Foundation. issue to be mentioned is the high age of our sample The founders had no role in study design, data collec- that might have introduced bias. It is well known tion and analysis, decision to publish, or preparation of that sexual behavior, as well as importance and the manuscript. interest in such activities, decreases as a function of Corresponding Author: Karin Rechsteiner, MSc, age. One might question the validity of including University of Zurich—Psychology, Binzmühlestrasse individuals aged 60 and older in studies investigat- 14/17, Zürich 8050, Switzerland. Tel:41-44-635-73-12; ing sexuality, as the reasons for sexual impairment E-mail: [email protected] in older women (e.g., due to menopause and/or Conflict of Interest: The author(s) report no conflicts of decrease in sex steroids) might be markedly differ- interest. ent from the factors affecting sexual function in younger individuals and might have masked the independent effects of trauma exposure and References PTSD. Nevertheless, exploration of sexuality in 1 Maercker A, Horn A. 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