The Overlooked Spiral of Trauma: Cumulative Spiritual Distress in Patients With Cancer and a History of Childhood Sexual Abuse

Recently, a Lancet article noted a staggering global age-standardized prevalence of childhood sexual violence at 18.9% for females and 14.8% for males even after excluding online sexual abuse and exploitation.1 Childhood sexual abuse (CSA) has long been recognized for its association with cancer diagnosis in adulthood, potentially through chronic inflammation, immune dysregulation, Human Immunodeficiency Virus (HIV) and other sexually transmitted infections, or behavioral risks such as tobacco and alcohol use.2 During cancer treatment, procedure- and provider-related triggers (eg, undressing, lying still, exposure of genitals, having one’s body touched/inspected, or head-and-neck immobilization from wearing a thermoplastic mask) can invoke feelings of diminished agency, lack of choice, and powerlessness that mirror one’s original exposure to sexual abuse.2,3 These triggers may lead to a sense of being retraumatized and further activate existential distress in cancer survivors. One study found that a greater extent of CSA-related powerlessness was associated with an increased “cancer victim identity,” which has been linked with a number of negative psychosocial consequences, including spiritual distress.4 Another study found that all CSA survivors interviewed (n=18) experienced recollections of abuse-related traumatic memories following a cancer diagnosis, despite 83% (n=15/18) having no recall of their abuse history prior to their cancer diagnosis.5 The potential for spiritual distress to compound across these 2 traumatic life events highlights a shared existential core that underlies both CSA survivorship and cancer survivorship: CSA, cancer, and cancer treatment all connote external disruptions in “taking away” a person’s control over their physical body. To illustrate, whereas CSA is an interpersonal violence against the physical body, chemotherapy as a medical procedure often induces unintended physiological changes. These changes, such as cachexia, hair loss, dull taste buds, and taste alterations, could be experienced by a patient as alienation from their “once-familiar” biological, bodily self. Ever since Balboni et al6 published their influential Delphi panel consensus identifying that spiritual needs are common among seriously ill patients and calling for future integration of spiritual care into routine healthcare, we have seen a notable increase of research on spirituality in palliative care. Yet, there remain significant gaps, including the following: (1) psycho-spiritual outcomes in CSA survivors diagnosed with cancer have only been minimally addressed in the literature, (2) statistics on the prevalence of CSA among adults with cancer remain unclear, and (3) the acceptability and effectiveness of spiritual care on this marginalized subgroup of cancer patients have remained largely understudied. As cancer care researchers, we are concerned with several implications from the knowledge gap: First, the paucity of research can pose challenges to inclusiveness in spiritual care research studies. Trauma history of patients with cancer can manifest as treatment interruptions, noncompliance, and dropouts.2 Accordingly, CSA-related spiritual distress may be an unmeasured factor for attrition rates observed in psycho-spiritual randomized controlled trials (RCTs). This could lead to “survival bias” in RCTs in terms of the effectiveness in addressing spiritual distress in patients with cancer who had lived through adverse childhood events. Additionally, this could hinder equitable access to psycho-oncological care for this understudied clinical population. Second, given the lack of empirical data, our understanding around the prevalence of spiritual distress in CSA survivors facing cancer can only be extrapolated from 2 separate distinct bodies of research: one examining spirituality in CSA survivors, and the other examining spiritual distress in patients with cancer. This approximation, however, risks underestimation, because CSA survivors diagnosed with cancer have been shown to experience “cumulative trauma”—reacting to cancer not only as a serious illness but also as “another bodily assault” compounding the original trauma.3 Third, variables like religiosity and affiliation with faith-based communities have often been positively associated with spiritual health in quantitative research. However, scholars have noted that multiple abuse-related “spiritual struggles” can emerge over the course of sexual violence survivorship, including feelings of spiritual alienation, sense of abandonment, existential anguish and grievance toward God/deity.7 These spiritual struggles can stem from (1) feelings of incongruence and tension with one’s own religiosity and religious identity, (2) cultural ideas of purity and submission often upheld in religion, or (3) stigmatization and silencing as potential reactions from other members of faith and religious communities.7 For CSA survivors diagnosed with cancer, abuse-related spiritual alienation can inhibit access to their own inner resources for spiritual coping during cancer survivorship. For instance, a personal history of sexual violence has been associated with higher anxiety levels in a large sample of patients receiving chemotherapy, suggesting that trauma may compromise the psychological capital needed for effective coping.8 In conclusion, our Insights article calls for attention to cumulative spiritual distress inflicted upon patients with cancer and a history of CSA. We appeal to nursing researchers to advance our field by (1) mapping the prevalence of CSA survivors diagnosed with cancer and (2) integrating a trauma-informed lens into research designs to improve patient participation in spiritual care research.