The long-term effects of child sexual abuse
- Determining the association between child sexual abuse and later outcomes
- A range of outcomes
- The impact of child sexual abuse on mental health
- Behavioural aspects of mental health functioning
- Interpersonal outcomes
- Physical health and overall developmental outcomes
- Gender differences in the long-term impacts of child sexual abuse and gaps in understandings of male victims/survivors
- A complex interplay
Behavioural aspects of mental health functioning
The behavioural manifestations of emotional distress and mental health problems present a quite consistent pattern in relation to the association between child sexual abuse and substance abuse problems, suicide, sexual risk-taking and other risky behaviours.
Alcohol and substance abuse in child sexual abuse victims
Research has long indicated a relationship between childhood abuse, including sexual victimisation, and subsequent alcohol and substance abuse (Mullen & Fleming, 1998). Victims of childhood abuse and neglect generally have been reported to be at greater risk of abusing alcohol and drugs (Min, Farkas, Minnes, & Singer, 2007), and survivors of child sexual abuse are at a heightened risk of developing an alcohol disorder and with an earlier age of onset (Zlotnik et al., 2006).
Population based studies also indicate that victims of child sexual abuse are more often found among adolescents and adults with alcohol and/or drug related disorders compared with non-abused populations (odds ratios ranging from 1.01 to 8.9) (Cutajar et al., 2010b, p. 814; Kendler et al., 2000). Survivors of child sexual abuse are also at greater risk of substance dependencies including not only alcohol but also nicotine dependency (Nelson et al., 2002). Moreover, research suggests that survivors of child sexual abuse are more likely than the non-abused population to struggle with alcohol and substance disorders over their entire lifetime. Molnar, Buka, and Kessler (2001) found that the percentage of women with lifetime alcohol dependence was 16% among child sexual abuse survivors, compared with 8% for non-abused women. The frequency was markedly higher for men, with 39% of male child sexual abuse survivors found to have lifetime alcohol dependence, compared with 19% of non-abused men.
There is increasing evidence of the bio-chemical underpinnings to alcohol and other drug abuse by adolescents and adults subjected to high levels of adversity and stress in childhood. Delima and Vimpani (2011), for example, pointed to the dampening effect of "alcohol and several of the commonly used illicit recreational substances" on the hyper-arousal PTSD symptoms. The use of such substances is therefore a means of "self-medication" in adolescents who have experienced maltreatment (p. 47). As indicated above, the link between child sexual abuse and PTSD and alcohol dependence is not straightforward and research suggests a series of indirect links are involved in these effects.
Risky behaviours and adjustment difficulties of child sexual abuse victims
Research and clinical experience indicates that survivors of child sexual abuse may be at greater risk of engaging in risky behaviours both as adolescents and as adults (Mason, Zimmerman, & Evans, 1998). In particular, this includes risky sexual behaviours but anecdotal and clinical information also point to other behaviours such as gambling and drug use, although there is little research that has specifically examined the link between child sexual abuse and gambling.
In adolescence, child sexual abuse has been associated with early onset consensual sexual activity, unprotected sexual intercourse, multiple sexual partners and teenage pregnancy (Senn, Carey, & Vanable, 2008; Upchurch & Kusunoki, 2004). In adulthood, similar sexual risk behaviours have been documented for survivors of child sexual abuse (Arriola et al., 2005; Cohen et al., 2000; Fergusson, Horwood, & Lynskey, 1997). For example, Wyatt, Guthrie, and Notgrass (1992) found that victims of child sexual abuse were more likely to engage in group sex and partner swapping on a frequent basis and in other types of sexual behaviours that increase the risk of sexually transmitted infections (STI). The findings of van Roode, Dickson, Herbison, and Paul (2009) suggest that risky sexual behaviours in survivors of child sexual abuse may vary with age and gender; for women survivors, increased rates were observed for the number of sexual partners, unhappy pregnancies, abortion, and STIs from age 18 to 21; thereafter the rates approached those of non-abused women. In contrast, for male survivors, the number of partners was significant from age 26 to 32 and the acquisition of herpes simplex virus type 2 from age 21 to 32. There is also evidence that gay men and bisexual men who were sexually abused in childhood were more likely than their non-abused counterparts to engage in unprotected anal sex, to trade sex for money or drugs, to self-report having HIV, and to have been involved in non-sexual violence (Jinich et al., 1998; Kalichman, Gore-Felton, Benotsch, Cage, & Rompa, 2004). These findings are consistent with other research which suggests that child sexual abuse is associated with later sexual risk behaviour in men as well as women (Senn et al., 2008). However, more research is needed that specifically examines the sexual risk-taking behaviour of male victims of child sexual abuse, and particularly those who have been subjected to clergy-perpetrated sexual abuse.
Some researchers have suggested that sexual risk taking by child sexual abuse survivors serves as a way of avoiding the emotional distress associated with abuse (Steel & Herlitz, 2005; Wright, Crawford, & Sebastian, 2007). However, other theoretical frameworks have also been put forward to explain sexual and other risk-taking behaviour among the victims of child sexual abuse. A number of researchers have focused on child sexual abuse as a key sexual experience characterised by negative elements and emotions including physical and cognitive exploitation and feelings of stigmatisation and social isolation; these in turn increase the victim's vulnerability to sexual experiences, particularly negative ones (Browning & Laumann, 1987; Finkelhor & Browne, 1985). Some researchers have also suggested that child sexual abuse leads to distortions that undermine the survivor's critical motivational, coping, and interpersonal factors, and that these in turn influence adult sexual behaviour and choices (Catania et al., 2008). More research is needed to better understand the relationship between child sexual abuse and subsequent risk-taking behaviour by victims generally, as well as the mediating role of other factors such as PTSD and alcohol and substance abuse.