Slide outline: The long-term effects of child sexual abuse

CFCA webinar - 5 August 2013


    • Judy Cashmore
    • 5 August 2013
  2. Background
    • Aim to deal with both:

      • Research issues and findings
      • Policy and practice implications
    • Based on CFCA Paper 11: Cashmore & Shackel (2013). The long-term effects of child sexual abuse.; and
    • Post-graduate course on Child Sexual Abuse at Sydney Law School
  3. The context
    • Four Corners: “Unholy Silence” 2 July 2012
    • VIC INQUIRY: June 2012 Handling of Child Abuse in Religious Organisations (Family and Community Development Committee)
    • NSW: Maitland-Hunter (Cunneen) Inquiry
    • NATIONAL ROYAL COMMISSION into Institutional Responses to Child Sexual Abuse
  4. Intelligent consumer of research
    • Being an intelligent reader of research requires:
    • An understanding of the basis research methods and issues in the field
    • Critical evaluation of the findings
    • Understanding the boundary between research and advocacy
    • Room for an emotional response but not driven by it
    • Understanding the implications for policy and practice
  5. Research issues
    • Teasing out the ‘effects’ of child sexual abuse and other adverse experiences in childhood is not straightforward
    • Estimating the prevalence is difficult – unknown ‘dark figure’ of those who never disclose, report
    • Source of the accounts of abuse and outcomes
    • Different definitions of child sexual abuse
    • Different research methodologies
  6. Teasing out the effects
    • Establishing causation?
    • Criteria for causal relationship
      • An association between abuse and later functioning
      • Abuse occurs before ‘effects’
      • Association or ‘effect’ is not due to some other extraneous factors eg other adverse circumstances
      • Some mechanism that can explain the ‘link’
    • Conflation – source of reports and outcomes
  7. Estimating the prevalence
    • Different definitions of abuse / forms it takes - ? estimates of prevalence and outcomes across studies, countries
    • Unknown ‘dark figure’ of those who never disclose, formally report
    • So that will compromise any comparison between:
      • those classified as ‘non-abused’ and
      • those who are ‘known’ to have been abused and reported
  8. Specialised and general populations
    • Specialised and general populations:

      • ‘General population’ studies – age range?

        • Smaller and larger scale studies
        • eg retrospective survey reports of ‘unwanted’ sexual experiences before age 14, 16
      • College students esp US research
      • Referred to or seeking medical services, support, and counselling – not identified as reported abuse
      • “Reported” abuse
        • Child victim-witnesses
        • Survivors – using specialist services
  9. Source of reports and outcomes
    • Contemporaneous or retrospective account of abuse? and effects?
    • Same source of account of abuse and impact?
    • Has the abuse been disclosed/reported?
    • Official or formal reporting to police and child protection?
  10. Distinguishing disclosure and reporting
    • Responding to research questions
    • Disclosure – did they tell anyone? At any time?
    • Formal / official reporting
      • Who did they tell?
      • When?
      • With what consequences?
  11. Definitions and measures
    • Christchurch longitudinal study - Retrospective 18+ yrs
    • Whether before the age of 16 -
      • anyone had ever attempted to involve them in any of a series of 15 sexual activities
      • when they did not want this to happen...
    • 3 categories
      • Non-contact
      • Contact - any form of physical contact
      • Oral, vaginal or anal penetration
  12. Definitions and measures
  13. Some instability in response
    • Christchurch longitudinal study *
      Repeated questions at age 18 and 21

      • Instability in response – any child sexual abuse

        • 86% - no CSA at both ages
        • 4.7% - CSA at both ages
        • 10% said CSA at age 18 but half did not “admit” at age 21
        • 3.8% said CSA at age 21 but not at 18
      • Not associated with psychiatric state at time of reporting
      • Wanting to forget / embarrassment
    • D. M. Fergusson, L. J. Horwood & L. J. Woodward (2000). The stability of child abuse reports: a longitudinal study of the reporting behaviour of young adults. Psychological Medicine, 30, 529-544.
  14. Disclosure rates
    • Substantial under-reporting of child sexual abuse

      • More so for males
    • Where child sexual abuse/assault known from official records but not reported in adulthood
    • Fallibility of memory and/or
    • Desire to forget and/or
    • Unwillingness to ‘volunteer’ info
      • Abuse by a family member and abuse at an early age – under 5 yrs – both less likely to be reported
  15. Research methodologies
    • More rigorous studies eg. large-scale longitudinal designs, twin studies, and data linkage studies

      • Australia – Cutajar et al, 2010; Nelson et al, 2002
      • NZ – Christchurch cohort study: Fergusson et al, 2008
      • US – Nationally rep samples, and prospective and twin studies: Brown et al, 1999; Molnar, Berkman et al, 2001
    • Meta-analyses – systematic cross-study measures eg Paolucci et al, 2001
      • See Cashmore & Shackel (2013) for references
  16. Consequences of child sexual abuse
    • Distortion and abuse of relationships – if known
    • Betrayal of trust
    • Sexualisation - sexualised behaviours
      • Often misunderstood in court proceedings
    • Trauma – stress response – brain development
      HPA axis = Hypothalamic – Pituitary - Adrena
  17. Consequences of disclosure and reporting
    • Being believed
    • Powerlessness - getting it to stop
    • Betrayal of trust
    • Child protection
    • Church / institution
    • Police
    • Criminal prosecution?
  18. Why did you believe someone else knew
    • Jodie Death (2013) “They did not believe me”: Responding to Child Sexual Abuse by Church Personnel in Australia
    • Incidents took place in his bedroom in monastery with others knowing I was alone with him with the door shut. They never spoke to me..”
    • “Brother was removed to another school”
    • “They witnessed and masturbated while they watched “
    • “One adult witnessed it, another was told about it by several parents”
    • “Because the priest (abuser) told them”
    • “I quite obviously hated him, and would avoid him at our house “
  19. Official Reporting (Death, 2013)
  20. Main reasons for reporting: Death (2013)
    1. To protect children
    2. The Church to accept responsibility for the abuse
    3. The individual to accept responsibility for the abuse
    4. My story to be heard by the Church
    5. To remove that individual from their position
    6. Counseling for myself
    7. Church investigation
    8. Police Investigation
    9. Criminal conviction
  21. Consequences: Experience in the criminal justice system
    • Being believed?
    • An equal playing field?
    • Being prepared?
    • Conviction/acquittal / aborted trial
    • Betrayal of trust
    • Treatment by police
    • Treatment by prosecution lawyers
    • Treatment by defence lawyers
  22. Criminal justice prosecutions - difficulties
    • Being able to tell ‘story’ – own voice
    • Adversarial cross-examination
    • Attack on credibility – twisted defence narrative in Legal fictions – “peripheral becomes central”
    • Misunderstandings and exploitation of myths re delayed disclosure and continued relationship
    • Problem of separate trials
    • Multitude of warnings to jury
  23. Main findings: LT “Effects”
    • Range of adverse outcomes for sexually abused children during childhood, adolescence and adulthood
    • But abuse is not destiny – not all experience adverse outcomes and timing of difficulties varies
    • Aspects of the abuse – relationship between the abuser and the child, age and gender of the child, betrayal of trust and manipulation, form of abuse as well as family and friends’ and other reactions to disclosure are key factors
  24. Consistent findings
    • Behavioural and mental health functioning

      • Anxiety, depression and suicidality
      • Alcohol and substance abuse
      • Risky behaviours including sexual behaviours
      • Interpersonal difficulties
        • Trust and intimacy, parenting and risk of re-victimisation
      • Involvement with criminal justice system
    • Range of physical health problems – stress-response related
    • Gender differences – greater problems? later disclosure and less support for males?
  25. Behavioural and mental health functioning
    • Diverse effects - child sexual abuse as “non-specific” risk factor

      • Anxiety and depression
      • Alcohol and substance dependence
      • Eating disorders
      • Post-traumatic stress disorder
      • Suicidality
      • Cumulative and additive/synergistic effects
  26. Alcohol and substance dependence
    • Life-time alcohol dependence rates

      • eg women 16% cf 8% for women (Molnar, Buka & Kessler (2001)
      • And higher for men – 39% cf 19% (non-abused)
    • Explanatory mechanisms – self-medication
      • dampening of hyper-arousal PTSD symptoms
    • Interactive additive effects:
      • With parental alcohol problems and other forms of maltreatment, adverse childhood events see Fenton et al (2013) Psychological Medicine
      • Childhood abuse and cannabis use psychosis “Greater than additive interaction” (Harley et al, 2010)
  27. Interactive synergistic effects
    • Harley et al. (2010)
    • Graphic of Cannibis use and childhood trauma interact additively to increase the risk of psychotic symptoms in adolescence
    • Comment: This slide shows that the prevalence of psychiatric disorders among Irish adolescents aged 12-15 who both used cannabis and had experienced trauma in the form of physical or sexual abuse and/or exposure to domestic violence was much higher than for those who had experienced trauma or used cannabis alone or had neither used cannabis or experienced trauma. There is also an interaction effect with adolescents who had experienced trauma more likely to use cannabis than those who had not.
  28. Risky behaviours
    • Increased likelihood of risky/harmful behaviours

      • Especially in adolescence
      • “Accidental” fatal overdoses
      • Gambling
      • Sexual behaviour/activity
        • Early onset consensual activity
        • Multiple partners
        • Unprotected intercourse STDs, unwanted pregnancies
  29. Mechanisms? Factors involved…
    • Explaining and accounting for association between CSA and risky sexual behaviours:

      • Child sexual abuse - severity
      • Learned helplessness
      • Low self-esteem
      • Sexualised behaviours
      • Early & risky sexual behaviour in adolescence
      • Drug and alcohol use
  30. Interpersonal difficulties
    • Trust and intimacy

      • Betrayal of trust and personal boundaries
      • Secrecy - confusion, guilt, shame, isolation
    • Parenting – different for males and females
      • Anxiety and lack of confidence parental stress
      • Other adverse circumstances – isolation, violence
    • Fathering
      • Anxiety and over-protectiveness
      • Concerns about own possible victim-to-offender pathway
      • As a healing experience
  31. Causal chain? Partnership outcomes at age 30
    • Christchurch longitudinal study – Friesen et al (2010)

      • Child sexual abuse - severity
      • Low self-esteem
      • Substance abuse
      • Early & risky sexual behaviour in adolescence
      • Early and more frequent cohabitation
      • Low relationship satisfaction
      • Inter-partner conflict and violence
  32. Re-victimisation
    • Sexually abused children and adolescents more likely to be sexually assaulted as adults

      • Teasing out the effects – proximal as well as indirect
    • Not just sexual victimisation
    • Likely mechanisms / mediators
      • Self-esteem
      • Discrimination and trust
      • Hyper-arousal – distinguishing actual/false alarms
  33. Involvement with criminal justice system
    • Victim-to-offender cycle – stigma and fear

      • An increased risk but vast majority of sexually abused chn do not go on to offend
      • Different types of studies and population base
      • Depends on starting point
    • Starting with CSA children …
    • Starting with offenders / prison / JJ detention …
  34. Involvement with criminal justice system
    • Starting with children who have been sexually abused

      • Greater likelihood of

        • Behaviour problems
        • Running away - survival crimes eg prostitution, stealing, drug offences
        • Juvenile offending
      • Sexual offending - mixed results but more likely if abuse as adolescent ie 12 yrs plus
      • Type of study important – follow-up
        • Ogloff et al (2012) – 31 yr follow up using Vic records
        • Sexual offending by males – 9% if 12+ yrs cf 3% (under 12) cf comparison group 1% overall
  35. Involvement with criminal justice system
    • Starting with adults, adolescents in detention

      • High proportion with history of maltreatment and social disadvantages and adverse childhood experiences
      • Overall average – studies 41-43%
      • Indig et al (2011) – NSW Health survey of JJ detainees
        • 39% of females and 5% males -- self-report CSA
        • 55% of females and 24% males – high psychological distress
        • 45 males – committed sexual offence
  36. Table/Fig 6.7.2 Any childhood abuse or neglect (scores above 'none to low')
    • Comment: This slide shows the percentage of young men and young women in custody as well as those who are Aboriginal and non-Aboriginal who had experienced any childhood abuse or neglect. The highest proportion was for young women in both 2003 and 2009 surveys - 77.8% and 80.5%. The other percentages for young men and non-Aboriginal young people were lower - ranging between 58.9% and 67.2% with the exception of Aboriginal young people in 2003 where the percentage reporting childhood abuse or neglect was 79.5%.
  37. Figure 1: Proportion of young people in NSW juvenile justic detention reporting experiencing any serious childhood abuse or neglect, by gender.
    • Cashmore (2011), p. 32.
    • Comment: This slide shows the percentage of young men and young women in custody in both 2003 and 2009 who reported they had experienced serious childhood abuse or neglect. The highest proportion was for young women in 2009 - at nearly 50%. The other percentages for young men in both 2003 and 2009 and young women in 2003 were lower - around 25%.
  38. Physical health problems
    • Range of physical health problems
    • Complex links involving behavioural, emotional, social and cognitive factors
      • Esp affecting health-promoting behaviours
      • Stress-response – HPA – hypothalamic-pituary – adrenal stress response
      • Affecting neuro-endocrine and immunological systems
    • Reduced life expectancy (Brown et al, American Journal of Preventive Medicine, 2009, 37(5), 389–396).
  39. Gender differences
    • Mixed results but under-reported sexual abuse of males and by males
    • Prevalence issues – severity, frequency, duration, relationship to offender
    • Boys and men less likely to disclose and report CSA
      Dynamics of child sexual abuse
      • ‘Real men’ – not ‘victims’ or vulnerable /sexual prowess
      • Fear of homosexuality – label and self-label
      • Fear of victim-to-offender cycle
      • More likely to be seen as instigator?
  40. Gender differences
    • Abuse by clergy

      • Boys more likely than girls – 75-80% of victims
      • Most common age – 11-14 years
      • Long delay to disclosure – average 25 years
        • John Jay College US – 2004 large-scale study
        • Parkinson, Oates & Jayakody 2010 – Anglican church
  41. Main messages – what do we know?
    • Complex picture – multiply determined ‘multiple pathways’ multiple problems
    • Interactive synergistic relationships – “more than additive”
    • Increased risk of adverse long-term effects of child sexual abuse but ..
      Abuse is not destiny
  42. What don’t we know
    • What is the effect of criminal prosecutions on survivors?

      • Do those who decide to report and engage in criminal proceedings fare better or worse? Depending on?
    • What is the impact of media coverage?
    • What is/will be the effect of the Royal Commission on survivors?
      • Do those who decide to engage with the Commission fare better or worse as a result? Depending on?
    • The evidence base for what works in treatment?
  43. Intelligent consumer of research
    • Critical evaluation of research findings is ‘critical’

      • Research rigour
      • Consistent patterns – not just single studies, outliers
      • Both quantitative and qualitative studies and ‘stories’
      • Peer review and journal quality – though not foolproof
    • Systematic reviews and meta-analyses
    • Keeping in mind:
      • Historical context
      • Cultural context
      • Other confounding factors – ‘multiple pathways’
  44. Intelligent application of research
    • Gap between what we know and what we don’t know
    • Gap between what we know and what we do
    • Critical importance of properly evaluated treatments and interventions
  45. Practice implications
    • Providing appropriate support and treatment

      • Not alone!
      • Can re-evaluate self-blame, guilt and helplessness
    • “No wrong door”
    • Rural and regional access
  46. And finally …
    • Thank you for listening and Any questions?

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