The impact of sexual abuse on body experience in adults with mild intellectual disability or borderline intellectual functioning

ABSTRACT

Background

Research is lacking on body-related consequences of sexual abuse in adults with mild intellectual disability or borderline intellectual functioning (MID-BIF), although the prevalence of abuse is high and body- and movement-oriented diagnostics and therapeutics seem warranted for this group.

Method

Body experience in adults with MID-BIF who were sexually abused (SA) and were not sexually abused (NSA) was compared using a self-report instrument, the Body Experience Questionnaire-mb, and an instrument to observe non-verbal psychomotor behaviour, the PsyMot-mb.

Results

The SA group showed significantly higher self-reported body awareness and more observed problems with body acceptance than the NSA group. No significant group differences were found for self-reported body satisfaction and body attitude.

Conclusions

Adults with MID-BIF who were sexually abused are more aware of their body signals, but less able to adequately attend to, tolerate, and interpret these signals. Therefore, body- and movement-oriented therapies hold promise for this group.

KEYWORDS:

• Sexual abuse
• mild intellectual disability or borderline intellectual functioning
• body awareness
• body satisfaction
• body attitude
• body acceptance

Sexual abuse is a worldwide problem and a violation of human rights that has far reaching consequences for human wellbeing and health (World Health Organization, 2013). A crucial but often overlooked impact of sexual abuse is its effect on the relationship victims have with their body (Van der Kolk, 2006, 2014). Research has shown that body experience in victims of sexual abuse is often negatively affected by the violation of the body they experience or by the threats to its physical integrity (Sack et al., 2010). Victims often experience dissatisfaction with their body or parts thereof (Jaconis et al., 2020); feelings of sexual unattractiveness (Kilimnik & Meston, 2016; Wenninger & Heiman, 1998); diminished sexual fulfilment (Scheffers et al., 2017); disgust or hate towards their body (Fallon & Ackard, 2002); and reduced vitality and health (Sack et al., 2010; Wenninger & Heiman, 1998). Furthermore, victims of sexual abuse may experience difficulties with attending to and processing body signals, such as (changes in) heartbeat, breath, and feelings of hunger, pain, or temperature (Van der Kolk, 2014). They may either deny even having those body signals or may feel overwhelmed by the signals (Van der Kolk, 2006).

The afore-cited studies all based their results on the experiences of individuals with (higher) than average intelligence quotient (IQ), whereas individuals with intellectual disability are especially at risk of sexual abuse (Mailhot Amborski et al., 2022; Tomsa et al., 2021). The estimated prevalence of sexual abuse in this group is 33%, with increases in prevalence as the disability rises from mild (24%) to severe intellectual disability (67%) (Tomsa et al., 2021). Evidently the rates in intellectual disability are higher than the estimated prevalence of 24% for individuals with (higher than) average IQ (Pan et al., 2021). Two recent reviews showed that the consequences of sexual abuse are generally similar for individuals with intellectual disability and individuals with (higher than) average IQ, and cover a wide range of psychological and behavioural problems, including symptoms of anxiety, depression or posttraumatic stress, and challenging or sexualised behaviour (McNally et al., 2021; Smit et al., 2019). However, body-related consequences, such as aggression and self-harm, tend to be more common in the intellectual disability population (McNally et al., 2021; Smit et al., 2019) due to limitations in their verbal communication skills and expression (Smit et al., 2019). One could therefore expect that individuals with intellectual disability who were sexually abused would have a disturbed or negative body experience, similar to or even greater than their peers with (higher than) average IQ. Although body- and movement oriented therapists, such as psychomotor therapists (Emck & Scheffers, 2019; Probst, 2017) often observe problems with body experience in individuals with intellectual disability who were sexually abused (Van de Kamp & Hoven, 2019), research on this topic is non-existent, as far as we could glean from the literature (Smit et al., 2019, 2022)

To obtain sufficient information about an individual’s body experience, an assessment should include a combination of self-report measures and psychomotor observations (Emck & Scheffers, 2019). Self-report measures that evaluate body experience are particularly valuable because they reflect a given individual’s subjective experiences (Emck & Scheffers, 2019). The Body Experience Questionnaire for adults with mild intellectual disability or borderline intellectual functioning (MID-BIF) (BEQ-mb; Smit et al., 2022) is a self-report measure that focuses on three domains of body experience: body awareness, body satisfaction and body attitude (Röhricht et al., 2005; Scheffers et al., 2017). Body awareness refers to the conscious perception of bodily states, processes, and actions based on proprioceptive and interoceptive signals (Mehling et al., 2009). Body satisfaction refers to the degree of satisfaction with the appearance or functionality of the body (Alleva et al., 2014). And body attitude refers to the cognitive (including perceptual) and affective evaluation of the body and its behavioural consequences (Pöhlmann et al., 2014; Scheffers, 2018).

Besides self-report measures, psychomotor observation may also provide valuable information about an individual’s body experience (Probst, 2017). Psychomotor observation tools are particularly useful for individuals who have limitations in their verbal communication and expression, such as individuals with intellectual disability (Bellemans & Van Putten, 2021; Emck & Van Damme, 2021), as well as for individuals who are not sufficiently aware of their feelings, cognitions and behaviours associated with, for instance, post-traumatic stress (Van de Kamp et al., 2018). These tools are based on the observational assessment of a psychomotor therapist, in a clinical context, of non-verbal information such as (movement) behaviour, body posture, and facial expression (Emck & Scheffers, 2019; Van de Kamp et al., 2018). In addition, psychomotor observation tools consist of movement activities in which the client can be observed and asked about their bodily feelings as experienced in the moment. Such an approach matches the needs and cognitive capabilities of individuals with intellectual disability (Emck et al., 2012; Kay et al., 2016). The PsyMot for adults with MID-BIF (PsyMot-mb; Smit et al., 2020) is an example of an assessment tool that focuses on body acceptance, a domain of body experience that pertains to the ability to attend to, tolerate, and interpret bodily signals and the accompanying (movement) behaviour (Emck & Bosscher, 2010; Smit et al., 2020). Body acceptance includes non-verbal aspects of body experience (i.e., noticing changes in body signals, regulating breathing, and locating, relaxing, and tightening body parts). Body acceptance thus also includes behavioural responses to body awareness.

To our knowledge, the BEQ-mb and the PsyMot-mb are the only instruments presently available for measuring body experience in individuals with intellectual disability. Since these instruments measure body experience specifically in adults with MID (IQ 50–69) and BIF (IQ 70–85), this study focuses on these groups. Adults with BIF were included because, in the Netherlands, they are accommodated in the same care facilities as adults with MID. In these care facilities, adults with BIF and MID are treated as a single group because they experience similar problems in cognitive and adaptive functioning (Wieland & Zitman, 2016).

Research is required to document and better understand the impact of sexual abuse on body experience in adults with MID-BIF in order to improve the early recognition of sexual abuse in clinical practice. The resulting knowledge is essential for the adequate use of body- and movement-oriented therapies that target problems with body experience in adults with MID-BIF. Against this background, the aim of this study was to compare body experience in adults with MID-BIF who had and had not been sexually abused. More specifically the following questions were examined:

1. Do adults with MID-BIF who were sexually abused differ from those who were not sexually abused in terms of their body awareness, body satisfaction, and body attitude as measured by self-report?

2. Do adults with MID-BIF who were sexually abused differ from those who were not sexually abused in terms of their body acceptance as assessed by psychomotor observation?

Based on the clinical observation of individuals with MID-BIF, and the literature on individuals with (higher than) average IQ, the following general hypothesis was examined: adults with MID-BIF who were sexually abused have more problems with body awareness, body satisfaction, and body attitude than adults with MID-BIF who were not sexually abused. Given the paucity of research on the impact of sexual abuse in adults with MID-BIF, we refrained from formulating more detailed hypotheses and sought instead to explore possible differences in body acceptance between the two groups.

Method

In this cross-sectional comparison study, the body experience in a group of adults with MID-BIF who were sexually abused were measured using the BEQ-mb and the PsyMot-mb and compared with those of a group of adults with MID-BIF who were not sexually abused.

Participants

Individuals with intellectual disability were recruited by 17 psychomotor therapists in 12 care facilities through non-probability convenience sampling. Inclusion criteria were: (1) IQ between 50 and 85, (2) aged 18 years or older, (3) sufficient command of the Dutch language, (4) ability to read at least at the lowest level (A1; Council of Europe, 2020), and (5) referral to psychomotor therapy (PMT). Exclusion criteria were: (1) symptoms including visual or motor disabilities that precluded participants from filling out a questionnaire and/or participating in movement activities, and/or (2) severe impairments in reality testing at the time of data collection, such as having a psychotic episode. Psychomotor therapists determined whether the potential participants were eligible for inclusion.

Based on the participant’s report and information about sexual abuse in their casefile, the participant was assigned to either the sexual abuse (SA) or non-sexual abuse (NSA) group in the data analysis stage of the study (see procedure). We chose not to rely solely on the participant’s report, because they may not have recognised the abuse, or may have been ashamed or reluctant to report the abuse (Gil-Llario et al., 2019). The SA group consisted of 24 participants (43%), including 18 participants (32%) with sexual abuse documented in their case file who reported sexual abuse by themselves, four participants (7%) who reported sexual abuse by themselves but for whom no sexual abuse was documented in their case file, and two participants (4%) who did not report sexual abuse by themselves although it was documented in their case file. The NSA group consisted of 32 participants (57%).

Table 1 summarises the main characteristics of the SA and NSA groups. There were no significant differences between the groups in terms of age, sex, IQ, psychiatric disorder(s) according to DSM-5, or experience with psychomotor treatment before participating in the study. Only on one variable was a significant difference found: more participants in the SA group reported to have experienced traumatic events other than sexual abuse (79%) than in the NSA group (50%; χ² (1) = 4.978, p = 0.026).

Table 1. Participant characteristics.

	Total group (n = 56)	SA group (n = 24)	NSA group (n = 32)	p
Age (M, sd)	33 (11)	33 (11)	33 (11)	0.935
Sex (n, %)
Male	27 (48)	10 (42)	17 (53)	0.396
Female	29 (52)	14 (58)	15 (47)
IQ (n, %)
BIF (IQ 70–85)	23 (41)	8 (33)	15 (47)	0.308
MID (IQ 50–69)	33 (59)	16 (67)	17 (53)
IQ (M, sd)
Total IQ^a	67 (8)	67 (8)	68 (9)	0.694
Verbal IQ^b	71 (8)	72 (11)	71 (12)	0.824
Performance IQ^c	69 (10)	68 (10)	70 (9)	0.696
Psychiatric disorder(s) according to DSM-5 (n, %)
Yes	45 (80)	19 (79)	26 (81)	1.000
No	11 (20)	5 (21)	6 (19)
Type of psychiatric disorder according to DSM-5 (n, %)
Neurodevelopmental disorders	19 (46)	6 (32)	13 (59)
Trauma- and stressor-related disorders	13 (32)	9 (47)	4 (18)
Disruptive, impulse-control- and conduct disorders	4 (10)	3 (16)	1 (5)
Schizophrenia spectrum and other psychotic disorders	4 (10)	2 (11)	2 (9)
Anxiety, depressive, bipolar and related disorders	12 (29)	8 (42)	4 (18)
Obsessive-compulsive and related disorders	1 (2)	1 (5)	0 (0)
Personality disorders	8 (20)	4 (21)	4 (18)
Substance-related and addictive disorders	11 (27)	6 (32)	5 (23)
Paraphilic disorders	2 (5)	1 (5)	1 (5)
Traumatic experiences other than sexual abuse (n, %)
Yes	35 (63)	19 (79)	16 (50)	0.030*
No	21 (37)	5 (21)	16 (50)
Psychomotor treatment (n, %)
Yes	51 (91)	21 (87)	30 (94)	0.642
No	5 (9)	3 (13)	2 (6)

*p < 0.05

^an = 53, 48, 48 (respectively total, verbal and performance IQ), ^bn = 30, 25, 26 (respectively total, verbal and performance IQ), ^cn = 23, 22, 22 (respectively total, verbal and performance IQ)

Little is known about the characteristics of sexual abuse in individuals with MID-BIF. This information could be useful for diagnostic and therapeutic purposes. Although this was not an aim of the study, detailed information about the sexual abuse is provided in the supplementary material for future reference (see Table I). According to the rubrics developed by Wissink et al. (2018), the following details of sexual abuse were noted: type of abuse, frequency of abuse, evidence of abuse, and perpetrator characteristics (i.e., sex, relationship with victim).

Procedure

The study was approved by the local ethics committee of the Faculty of Behavioural and Movement Sciences of the Vrije Universiteit Amsterdam (VCWE-2020-138). Data collection took place between September 2020 and December 2021.

Psychomotor therapists (n = 17) working in a care facility for individuals with intellectual disability were recruited through non-probability convenience sampling via the authors’ professional networks. Recruitment took place on an individual level (i.e., of psychomotor therapists) rather than an institutional level. Therapists received an information letter about the study and were invited for an one-on-one meeting to provide more detailed information. If willing to participate, the psychomotor therapists were recommended to ask the manager of the care facility they worked for permission to invite individuals to be included in the study. If permission was given, the psychomotor therapists checked whether clients in their case load met the inclusion criteria for participating in the study (see Participants). If so, they invited them for a one-on-one meeting to inform them about the study. Potential participants received an information letter, which they read, together with the therapist, to ensure they fully understood what participation would entail. They were given two weeks to decide whether or not they wanted to participate in the study. If interested, the potential participants and their legal representatives (if required) were invited to sign an informed consent form.

Data for each participant were collected during two standardised PMT sessions that lasted about 1 hr. The first session was used for the self-report questionnaire and a semi-structured interview (first part of the PsyMot-mb). In the second session, the psychomotor observation was conducted (second part of the PsyMot-mb). All psychomotor therapists were trained by the first author (MJS) on how to administer the measurement instruments.

During the first session, the therapists asked the participant whether they had been sexually abused.¹ The participant could answer “yes” or “no” and was not obliged to further discuss the abuse, but was allowed to do so if feeling sufficiently safe. Independent of this answer, reports of sexual abuse were searched for in the participant’s case file. The SA group consisted of participants who reported the sexual abuse by themselves (answered “yes”) and/or for whom the sexual abuse was documented in their case file. If the sexual abuse was not documented in the participant’s case file and they answered “no” to the question about sexual abuse, the participant was categorised in the NSA group.

Measures

Registration form

A registration form for recording the participant characteristics was developed by the authors (MJS, CE, MS). The characteristics in question were extracted from the participant’s case file. The participant characteristics included age, sex, IQ levels (total, verbal, and performance), psychiatric disorders according to DSM-5, traumatic experiences other than sexual abuse, and experience with psychomotor treatment prior to participating in the study.

BEQ-mb

The BEQ-mb, a 30-item self-report questionnaire, was used to measure three distinct domains of body experience: body awareness (e.g., “I feel it in my body when I am cold”), body satisfaction (e.g., “I am satisfied with how I look”), and body attitude (e.g., “I like to hug”) (Smit et al., 2022). The items were scored on a 4-point Likert scale ranging from never (1) to always (4) with pictorial representations of the response alternatives, and a higher score respectively indicating higher awareness, a more positive attitude and greater satisfaction. Internal consistency of the pilot version of the BEQ-mb was found to be good for the total scale (α = 0.84) and the body awareness (α = 0.84) and body satisfaction subscales (α = 0.80), but low for the body attitude subscale (α = 0.43). Test-retest reliability of the pilot version of the BEQ was found to be excellent for the total scale (ICC = 0.87), and for the body awareness (ICC = 0.85), body satisfaction (ICC = 0.76), and body attitude (ICC = 0.85) subscales (Smit et al., 2022). Based on the results of the pilot test, the BEQ-mb was adapted in order to improve the internal consistency of the body attitude subscale, resulting in the BEQ-mb used in this study. The reliability and validity of this adapted version remain to be established (Smit et al., 2022).

PsyMot-mb

The PsyMot-mb, a standardised tool for the psychomotor assessment of adults with MID-BIF, was used to measure body acceptance, defined as the ability to attend to, tolerate, and interpret body signals (Smit et al., 2020). Besides the measurement of body acceptance itself, the PsyMot-mb focusses on the (behavioural) problems arising from disturbances in the aforementioned aspects of body acceptance. The PsyMot-mb is based on a combination of the subscale “body acceptance” of the PsyMot for children (Emck & Bosscher, 2010) and the PsyMot for individuals with intellectual disability and challenging behaviour (PsyMot-ID) (Kay et al., 2016).

The PsyMot-mb consists of 13 items (e.g., “sensation of pain,” “breathing,” “managing body signals”) scored on a 5-point Likert scale ranging from no problems (0) to extremely severe problems (4). The items are scored based on a semi-structured interview and an observation session. Examples of questions posed during the semi-structured interview are “Do you feel tense sometimes?,” “If so, how do you notice?,” “If so, where in your body do you notice?,” and “If so, what do you do when you feel tense?” The observation session consisted of three movement activities: running, a free choice movement activity, and a relaxation exercise. During those activities, participants became physically active and thereby enabled the psychomotor therapist to observe the participants, and ask them, for example, if they noticed any change in their body signals, such as breathing, heart rate, sweating or warmth. The relaxation exercise was introduced to assess whether, for example, the participants were able to regulate their breathing, to focus on and locate body parts, and to tighten and relax muscle groups. The PsyMot-ID was shown to be a useful instrument in clinical practice with good inter-rater reliability on all subscales (kappa range: 0.71–1; Kay et al., 2016).

Data analysis

All analyses were conducted using IBM SPSS Statistics software version 28. Mean (sub)scale scores were not computed for participants who had more than two missing item scores. Two participants in the SA group scored more than two standard deviations (SD) below the mean of the subscale body satisfaction, and one participant in the SA group scored more than two SD above the mean of the PsyMot-mb. However, since these scores seemed legitimate observations, reflecting a degree of variation that is to be expected in a heterogeneous clinical sample such as the present one, we decided to keep their scores in the analyses (Laurikkala et al., 2000). Normal distribution of the variables was checked using the Shapiro–Wilk test.

Chi-squares (χ²) were used to analyse group differences in sex and IQ (MID or BIF) because expected cell frequencies of these variables were greater than 5 (Field, 2009). Group differences in experience with psychomotor treatment before participating in the study, psychiatric disorders according to DSM-5, and traumatic experiences other than sexual abuse, were analysed by applying Fisher’s exact tests because expected frequencies of these variables were 5 or lower (Field, 2009). Group differences in age and IQ levels (total, verbal, and performance) were analysed using independent t-tests.

Independent t-tests were conducted to compare mean values between the two groups in BEQ-mb scores and PsyMot-mb scores. Significant mean differences were expressed in Cohen’s d and considered large if > 0.80, moderate between 0.79 and 0.50, and small between 0.49 and 0.20 (Cohen, 1988). Although we conducted multiple t-tests, we refrained from applying the Bonferroni correction because this correction increases the risk of type II errors and missing true positive results that could be further investigated in future research (Feise, 2002; Perneger, 1998). Instead, effect sizes and confidence intervals (CI) were reported to assess the magnitude of the differences and the extent of any uncertainty (Cumming, 2014; Sullivan & Feinn, 2012).

Additionally, to control for differences between the two groups on variables independent of sexual abuse, hierarchical regression analyses were conducted to predict the BEQ-mb scores and PsyMot-mb scores based on a model with only the group variable (step 1), and a model with both the group and a dummy for the presence of traumatic experiences other than sexual abuse (step 2).

All statistical analyses were performed two sided, using a significance level of 0.05.

Results

Table 2 shows the mean differences in BEQ-mb total and subscale scores, as well as the PsyMot-mb scores, between the participants in the SA and NSA groups. Differences in body experience between both groups were significant and moderate for the subscale body awareness on the BEQ-mb and for the PsyMot-mb. The participants in the SA group scored higher on the subscale body awareness on the BEQ-mb and the PsyMot-mb than the participants in the NSA group.

Table 2. Mean differences in BEQ-mb total- and subscale scores and PsyMot-mb scores between the SA and NSA groups.

	SA group (n = 24)	NSA group (n = 32)	df	t	p	95% CI	Cohen’s d
BEQ-mb (M, sd)	2.89 (0.44)	2.89 (0.43)^a	52	0.004	0.996	−0.24, 0.24
Subscales BEQ-mb (M, sd)
Body awareness	3.19 (0.48)	2.90 (0.52)^b	53	2.079	0.042*	−0.56, −0.01	0.57
Body satisfaction	2.55 (0.82)	2.89 (0.66)	54	−1.704	0.094	−0.06, 0.74
Body attitude	2.79 (0.47)	2.89 (0.38)	54	−0.888	0.379	−0.13, 0.33
PsyMot-mb (M, sd)	1.47 (0.72)	1.05 (0.59)	54	2.400	0.020*	−0.77, −0.06	0.65

^an = 30, ^bn = 31

Additional multivariate analyses were performed to examine whether the significant differences between the groups could also be explained by the difference in traumatic experiences other than sexual abuse (see Table II in the supplementary material). In step 1, results indicated that sexual abuse significantly predicted scores on the subscale body awareness and the PsyMot-mb, explaining respectively 5.8% and 9.6% of the variation. Both regression models were significant.

In step 2, the variable traumatic experiences other than sexual abuse was included in all models. However, adding this variable accounted for only an additional 1.8% and 1.1% of the variation in the scores on the subscale body awareness and the PsyMot-mb. Both regression models were not significant.

Discussion

The main aim of this study was to compare body experience in adults with MID-BIF who were and were not sexually abused. Differences between the SA and NSA groups on three domains of body experience, i.e., body awareness, body satisfaction and body attitude, were measured by self-report, and differences between the SA and NSA groups on the body acceptance domain were measured using psychomotor observation. Both groups were comparable in terms of participant characteristics, except for the variable traumatic events other than sexual abuse, with significantly more traumatic events reported in the SA group. An additional analysis showed that the higher prevalence of trauma other than sexual trauma in the SA group provided no explanation for the group differences observed using the self-report and psychomotor observation instruments. Nevertheless, the higher prevalence of trauma other than sexual trauma in the SA group is an important finding in its own right, because it illustrates both the vulnerability of the target group and the complexity of their problems.

The participants in the SA group scored significantly higher on self-reported body awareness than the participants in the NSA group. This indicates that participants in the SA group were more aware of their body signals (e.g., change in breath, feelings of hunger, pain, or temperature) than those in the NSA group. Possibly, this higher body awareness indicates that the participants in the SA group may have felt overwhelmed by their body signals; they may have been hyperalert or overly aware of their body signals, also known as a state of hyperarousal (Ogden et al., 2006; Van der Kolk, 2006). Hyperarousal is a survival mechanism, which enables an individual to assess threat, and to (rapidly) select resources for safety. However, in victims of traumatic events, hyperarousal is often present long after the threat of the trauma has disappeared. They perceive harmless triggers as dangerous, resulting in too much arousal to process information effectively, which is not adaptive over time. This makes it difficult for victims of traumatic events to adequately interpret and rely on their body signals, which in turn may lead to inadequate behavioural decisions (Ogden et al., 2006; Van der Kolk, 2014). Heightened awareness of body signals is thus not particularly helpful in adults with MID-BIF who were sexually abused. This insight is in line with the study by Mehling et al. (2009), who considered heightened body awareness as potentially distressing and maladaptive, and is also in alignment with our hypothesis that participants in the SA group would experience more problems with body awareness than those in the NSA group.

In contrast with our hypothesis, participants in the SA and NSA groups did not differ in their self-reported body satisfaction or body attitude. With respect to body satisfaction, this might be related to the fact that, in general, individuals with intellectual disability have positive beliefs about their body and tend to underestimate their body size (Eden & Randle-Phillips, 2017). Moreover, their image of the ideal body may be different to individuals with (higher than) average IQ because individuals with intellectual disability might be protected by their environment from negative discussions about (their) appearance. As such, they are less susceptible to societal pressures about the ideal body image and may lack the ability to generalise to themselves concepts such as the ideal image of the body in society (Eden & Randle-Phillips, 2017). The fact that no significant differences were found in body attitude between the groups may be related to the low internal consistency of the subscale body attitude of the BEQ-mb. Body attitude is a multifaceted concept (Röhricht et al., 2005), which includes behavioural responses to body awareness. It is therefore difficult to operationalise in an internally consistent manner using questionnaires (Smit et al., 2022). As a result, this subscale might not be robust enough to detect differences and might thus be less suitable for investigating problems in body attitude as a singular concept. Therefore, the results of the body attitude subscale should be interpreted with caution. Further research is needed to substantiate these explanations and suggestions.

Based on the findings of the psychomotor observations, the participants in the SA group had significantly more problems with body acceptance than those in the NSA group. More specifically, the participants who were sexually abused were less able to adequately attend to, tolerate, and interpret body signals, resulting in more problematic (movement) behaviour, compared to those without sexual abuse. These findings are in line with the conceptual framework of Price and Hooven (2018) according to whom trauma affects the ability to access (i.e., to pay attention to and perceive) body signals and to appraise (i.e., interpret and make behavioural decisions based on) these body signals. Moreover, the problems with body acceptance reported in the PsyMot-mb by the therapists possibly reflect the behavioural responses to hyperarousal in the SA group.

In general, our study provides an indication of the impact of sexual abuse on the victims’ relationship with their body. Although differences in group means on our measures of body awareness and body acceptance were clearly present, proper diagnostics are required to determine the impact on an individual level. From this perspective, it is advisable to include an evaluation of body experience in the treatment of sexual abuse, making use of body- and movement-oriented interventions such as PMT. Since evidence for these interventions in individuals with MID-BIF who were sexually abused are scarce (Stobbe et al., 2021), the development of effective body- and movement-oriented interventions that target problems in body experience in this group is highly warranted. Furthermore, it is advisable to include the assessment of body experience in the standard assessment and admission procedures for individuals with MID-BIF, especially in light of the high prevalence of sexual abuse in this group. This may improve the early recognition of sexual abuse and related problems in this group. Additionally, to gain a more encompassing understanding of body experience, different types of instruments need to be used for its assessment, in particular self-report questionnaires and psychomotor observation tools (Emck & Scheffers, 2019).

To our knowledge, this is the first study examining body experience in adults with MID-BIF who were sexually abused, which used a combination of self-report and psychomotor observation as assessment tools. Another strength of this study, considering the sensitivity of the topic, and the vulnerable population, is the relatively large sample consisting of participants from 12 different care facilities throughout the Netherlands. This contributes to the generalisability of the findings to individuals with MID-BIF accommodated in Dutch care facilities.

Besides these strengths there are also a few noteworthy limitations and recommendations for future research. First, from a statistical perspective, the sample size was too small to comply with the standard power level of 0.80 recommended by Cohen (1988). This might account for the lack of significant differences between the SA and NSA groups on body satisfaction and body attitude. Also, the heterogeneity within the sample in terms of participant characteristics and characteristics of the sexual abuse may have led to a relatively small level of variance explained by the effect.

Second, the possibility of observer bias exists for the PsyMot-mb, a bias that may have influenced the observations in two ways. Prior to the interview and observation session, the psychomotor therapists knew whether the participant was categorised in the SA or NSA group, and this may have led to under- or overreporting during the psychomotor observation and, therefore, could have affected especially the information where problems in body acceptance were concerned (Jager et al., 2020). Moreover, the risk of diagnostic overshadowing is present in individuals with intellectual disability (Mevissen & de Jongh, 2010), which may have led to attributing problems in body experience to the intellectual disability, instead of the sexual abuse, resulting in a possible underreport of problems in the broad domains of body experience.

Third, the sample in the present study was a selective group of clients who had a referral to PMT and of whom the majority had experience with PMT prior to participating in the study. Since body experience is a primary focus of PMT (Bellemans & Van Putten, 2021; Emck & Scheffers, 2019; Probst, 2017), it could be that problems in body experience had already been reduced or treated through the PMT. Moreover, no conclusion could be drawn on the severity of the problems in body experience, because norm scores for the BEQ-mb and PsyMot-mb from adults with MID-BIF in a non-clinical setting were not yet available.

Finally, it is known that psychiatric disorders, such as neurodevelopmental disorders, trauma- and stressor-related disorders, and depressive disorders, are often related to problems in body experience (e.g., Emck et al., 2012; Garfinkel et al., 2016; Scheffers et al., 2017, 2019). However, the role of psychiatric disorder(s) as a third concurrent variable was not investigated due to the heterogeneity and small sample sizes of the specific psychiatric diagnoses made according to the DSM-5.

In view of these limitations, we recommend future studies on body experience in sexually abused adults with MID-BIF to preferably not inform the therapists about the group to which the participant belongs (i.e., SA or NSA). Future studies should also be longitudinal, use non-clinical comparison groups, and take into account the role of third variables such as psychiatric disorders. Furthermore, norm-scores on the BEQ-mb and PsyMot-mb from adults with MID-BIF in a non-clinical setting need to be established.

Conclusion

This study aimed to examine body experience in adults with MID-BIF who were sexually abused by comparing self-reported and observational measures of body experience in adults with MID-BIF who had and had not experienced sexual abuse. The group with experiences of sexual abuse was found to be characterised by higher self-reported body awareness in combination with problematic body acceptance as reported by the therapist on the basis of structured psychomotor observations. No significant differences were found for the scores of self-reported body satisfaction and body attitude. However, due to the small sample size, the heterogeneity of the group, and the possibility of observer bias, the present results need to be interpreted with caution and used as a basis for further research on body experience in individuals with MID-BIF. Nevertheless, the findings of the study demonstrate that the development and evaluation of interventions that target problems in body experience in the treatment of individuals with MID-BIF who were sexually abused are highly warranted.

Acknowledgements

The authors wish to thank David Mann for editing the final version of the manuscript before submission.

Disclosure statement

No potential conflict of interest was reported by the author(s).

Data availability statement

The data underlying the findings of this study are available on request from the corresponding author. The data are not publicly available in view of privacy regulations. All authors have read and approved the present version of the manuscript and agreed with the order of authors as listed on the title page.

Additional information

Funding

This work was supported by SIA-RAAK [grant number 02.127].

Notes

1 Sexual abuse refers to “any sexual activity that a victim does not fully comprehend, is unable to give informed consent to, or for which the victim is not developmentally prepared, or that violate the laws or social taboos of society” (World Health Organization, 1999, p. 15).