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
There is increasing evidence that children who have been abused, and in particular sexually abused, have greater difficulties with interpersonal relationships and especially trust compared with non-abused individuals. Given the betrayal of trust and violation of personal boundaries involved in child sexual victimisation, this is not surprising. In addition, the secrecy and often the fear of exposure creates a sense of shame, guilt and confusion that disrupts the child's "internal working model" according to which we all interpret the world. This affects how children and then adults understand and construe the motives and behaviours of others, and how they handle stressful life events. Medical and neurobiological research is throwing new light on the mechanisms underlying atypical and over-reactive stress reactions (see below).
Intimate relationships and parenting
There is some evidence for greater difficulties in interpersonal and particularly intimate relationships among adults who were sexually abused in childhood. These include increased instability in relationships, more sexual partners, an increased risk of sexual problems and greater negativity towards partners (Isley, Isley, Freiburger, & McMackin, 2008; Roberts, O'Connor, Dunn, Golding, & ALSPAC Study Team, 2004). Qualitative research including reports from women, indicates that pregnancy, childbirth and motherhood can trigger difficulties, emotional distress and lack of confidence and self-esteem (Sperlich & Seng, 2008). In a large-scale longitudinal prospective study in England, the Avon Longitudinal Study of Parents and Children, Roberts et al. (2004) reported that after adjusting for other childhood adversities, child sexual abuse was associated with "poorer psychological well-being, teenage pregnancy, parenting behaviours, and adjustment problems" (p.525) in their own children. The mothers' anxiety and lack of confidence in parenting mediated the association between child sexual abuse and the perceived quality of their relationships with their own children and their children's adjustment. In a smaller US study, the association between child sexual abuse and parenting outcomes (including parental stress, feelings of competence and discipline strategies) disappeared after accounting for the mother's depression and the current partner's violence (Schuetze & Das Eiden, 2005).
There is little research concerning fathering after childhood sexual abuse, but sufficient to indicate significant concerns among such fathers in relation to them being over-protective, nervous about physical contact with their children, and being fearful of becoming abusers themselves (Price-Robertson, 2012a). Fatherhood for some may be a "healing experience", but for others it may represent "a catalyst for the resurfacing of trauma" (Price-Robertson, 2012a, p. 4). The implications are for appropriate awareness and sensitive support and services for these men.
Re-victimisation of child sexual abuse victims
A large body of research has focused on the relationship between sexual victimisation in childhood and later "re-victimisation" in adolescence and adulthood. The research in this area has expanded its conception of re-victimisation from an initial narrow focus on the risk of future sexual assault (Shields & Hanneke, 1988; Wyatt et al., 1992; Stevenson & Gajarsky, 1991) to include a range of different types of traumas and victimisation experiences across a child victim's lifetime (Banyard et al., 2001). Research in this area has used college and community samples as well as specialised (e.g., psychiatric inpatients, outpatients and incest group members) or convenience samples (Widom, Czaja, & Dutton, 2008). Most studies have used cross-sectional and retrospective designs; very few studies have examined the risk of re-victimisation longitudinally. There has also been little attention to possible gender differences in re-victimisation.
Some earlier studies reported no association between child sexual abuse and the risk of later victimisation (Briere & Runtz, 1987; Mandoki & Burkhart, 1989). More recently, Widom et al. (2008) examined the relationship between child abuse and neglect (including child sexual abuse) and re-victimisation, in one of the few large-scale prospective long-term studies. Spanning a wide range of traumatic and victimisation experiences, this study found that victims of multiple forms of childhood abuse and neglect were most at risk of lifetime traumas and re-victimisation experiences. Victims of child sexual abuse (in the absence of other forms of abuse or neglect) were only marginally at greater risk of re-victimisation compared with a comparison group and were not at any greater risk of re-victimisation compared with victims of other types of childhood abuse and neglect. This study also specifically examined the effect of gender on the risk of re-victimisation, reporting that overall women with a history of childhood abuse were more likely to experience trauma and re-victimisation in adulthood. However, when it comes to sexual re-victimisation specifically, although both genders were at greater risk compared with the comparison group, the risk was significantly stronger for men with a history of childhood abuse and neglect.7
Overwhelmingly, however, the findings of other research suggest that victims of child sexual abuse are generally at an increased risk of re-victimisation. More specifically, women who have a history of child sexual abuse are at least twice as likely to experience adult sexual victimisation (Classen, Palesh, & Aggarwal, 2005; Maker et al., 2001). The severity of child sexual abuse may also be associated with the risk of re-victimisation, with those who have been subjected to more intrusive types of child sexual abuse, to multiple experiences and of longer duration at an increased risk of sexual victimisation (Arata 2000; Nelson et al., 2002). Fleming, Mullen, Sibthorpe, and Bammer (1999), for example, found that child sexual abuse involving penetration tripled the risk for rape as an adult. Other research, however, has found that less severe child sexual abuse may be sufficient to place the victim at higher risk of later sexual assault (Maker et al., 2001; West, Williams, & Siege, 2000). The relationship between the perpetrator of child sexual abuse and the victim may also affect the risk of re-victimisation, although the results have been mixed. Kessler and Bieschke (1999) reported that incestuous abuse increased the risk of adult victimisation more than peer abuse and non-familial abuse.
Various explanations have been advanced to explain the relationship between child sexual abuse and later re-victimisation. These include: (i) the acquisition of inappropriate sexual behaviours; (ii) learned helplessness; and (iii) diminished self-efficacy (Krahe, Scheinberger-Olwig, Waizenhofer, & Kolpin, 1999). Some research suggests that the link between child sexual abuse and later sexual re-victimisation is not a direct one but rather one mediated by other variables, such as higher levels of consensual sexual activity and a greater number of sexual partners (Fergusson et al., 1997; Krahe et al., 1999). One area that has more recently attracted attention is the possible role of PTSD as a potential mediator in the abuse-re-victimisation relationship. Theorists have suggested that PTSD symptoms may impair a woman's ability to accurately detect danger cues, impair responsiveness to trauma-related cues, or possibly inhibit self-protective behaviours (Risser, Hetzel-Riggin, Thomsen, & McCanne, 2006). Risser et al. (2006) found that the hyper-arousal symptoms of PTSD play the primary role in explaining the association between child sexual abuse severity and adult sexual re-victimisation. Put simply, the findings of this research suggest that if:
a woman experiences high levels of hyper-arousal on a consistent basis … she may lose her ability to discriminate between real threats and false alarms, and she may therefore begin to disregard legitimate warning cues. In turn, this could increase her risk of future sexual victimization. (Risser et al., 2006, p. 688)
Ullman, Najdowski, and Filipas (2009) found that substance abuse and problem drinking may play a role in both "numbing" PTSD symptoms and increasing the risk of further sexual victimisation. The findings of this study suggested that "once PTSD symptoms and problem drinking behaviours are accounted for, CSA does not directly predict future victimization" (p. 379). In other words, "child sexual abuse-related sequelae may indirectly contribute to increased risk of additional re-victimization, even in women who have experienced [adult sexual assault]" (p. 379).
Although still sparse, some research has started to emerge on the link between child sexual abuse of boys and sexual re-victimisation. For example, Elliot, Mok, and Briere (2004) found that men who reported being sexually assaulted as adults were 5 times more likely to have experienced childhood sexual abuse. More recently, in a large study of US male college students (n = 1,002), Aosved, Long, and Voller (2011) reported that men with a history of child sexual abuse were more likely to report a sexual assault in adulthood than men without. They were also more likely to indicate that they had adjustment difficulties in adulthood (37% compared with 15%, respectively). Overall, victims of child sexual abuse have been found to experience more traumatic events over time compared with non-victims, particularly traumatic events of a personal nature (Banyard et al., 2001).
Research also suggests that children and adolescents who have experienced child sexual abuse are at a heightened risk of re-victimisation even prior to adulthood. Swanston et al. (2002), in a NSW based study of 183 children with substantiated sexual abuse, found these children were at an increased risk of all forms of abuse and neglect subsequently. One in three children was subsequently the subject of an abuse or neglect notification. Krahe et al. (1999) reported that female victims of child sexual abuse were at greater risk of subsequent unwanted sexual contact in adolescence; in particular, this study reported that victims of child sexual abuse were especially at risk of experiencing severe forms of sexual aggression.
Further research on the risk of later re-victimisation of victims of child sexual abuse is important so that pathways to re-victimisation can be better understood and targeted interventions can be directed to prevent re-victimisation and build the resilience of victims.
Subsequent offending by child sexual abuse victims
Research in this area comprises two main sources of data: (i) follow-up studies of child sexual abuse victims; and (ii) retrospective studies involving offender and prisoner samples. A number of studies deal with offending in general and others focus on sexual offending. Whether or not there is a comparison group as well as the particular starting point - either starting with those who are known to have offended in various ways, or starting with children who were sexually abused - makes a difference to the type of conclusions that can be drawn. The conclusions from these studies therefore need to be interpreted with some care, and must be clear about the dangers of suggesting that there is a causal "victim-to-offender" link, particularly for sexual offending (Price-Robertson, 2012b).
Starting with children who have been sexually abused, there is evidence in several comparison and follow-up studies of a greater likelihood of behavioural problems, running away, vandalism and juvenile offending among those who had been sexually abused than those who were not sexually abused (Chandy, Blum, & Resnick, 1996; Smith & Thornberry, 1995; Widom, 1996). Running away is of course likely to render children and adolescents more vulnerable and more likely to commit survival crimes, including stealing and prostitution (Chandy et al., 1996). Adolescents and adults who were sexually abused have also been found to be more likely to be arrested for drug offences (Siegel & Williams, 2003; Widom, 1989) and property crime (Widom, 1989). The findings in relation to violence are mixed, with some studies finding an increased likelihood of violence and aggression (Hussey, Chang, & Kotch 2006; Siegel & Williams, 2003; Swanston et al., 2003) and others finding less risk or no greater likelihood (Widom, 1989; Widom & Maxfield, 2001). In Widom's US studies reporting on children who were physically or sexually abused at or before the age of 11, those who were sexually abused were less likely to be arrested for any sex crime than those who had been physically abused or neglected (Widom, 1996).
In a large-scale Australian study, Ogloff, Cutajar, Mann, and Mullen (2012) followed-up 2,759 substantiated cases of child sexual abuse in Victoria over a 31 year period and compared this group with 2,677 people drawn from the general population. They found that almost a quarter (24%) of child sexual abuse victims had a recorded offence compared with only 6% of the comparison group. Further, the average number of charges was significantly higher for child sexual abuse victims (32%) compared with the comparison group (19%). Child sexual abuse victims were also more likely to have received a custodial sentence compared with their general population peers (4% vs 0%). Overall, both male and female child sexual abuse victims were more likely to have been charged with an offence than those in the general population, with women 6.71 times more likely and men 4.34 times more likely to have been charged. In terms of the nature of offences, child sexual abuse victims were significantly more likely to be charged with all types of offences with a significantly higher charge rate particularly for sexual offences (7.6 times), violent offences (8.2 times) and breach of orders (10 times). Male victims of child sexual abuse were particularly likely to have been charged with a sexual crime; 5% of male victims of child sexual abuse were convicted of a sexual offence compared with 1% of male controls. An association was also found between the age of victimisation for males and offending behaviour; 9% of males victimised at 12 years of age or older had been convicted of a sexual offence, compared with only 3% of males sexually abused under 12 years of age. This difference was not found for female victims.
Starting with those who have committed offences and have been "caught" offers a different perspective. While the vast majority of those who have been sexually abused do not go on to abuse others, retrospective self-report studies of child sex offenders indicate that possibly as many as 75% of offenders were sexually abused as children, with rates generally reported in the range of 41-43% (Johnson et al., 2006; Nathan & Ward, 2002; Ogloff et al., 2012). Overall, studies of offender populations indicate a higher rate of child sexual victimisation amongst juvenile and adult offenders compared with the general population.
In a recent Australian study of 361 young people in juvenile detention centres in New South Wales, Indig et al. (2011) reported that 5% of the males and 39% of the females indicated they had been sexually abused as children, with little difference between Aboriginal and non-Aboriginal participants (about 10%). The reported levels of high psychological distress were similarly markedly higher for females than for males (55% compared with 24%) as were their reports of ever having considered committing suicide (28% compared with 14%). A sexual or aggravated crime was the most serious offence in relation to their current detention for 4% of males, and for none of the females. In a study of male (n = 1,030) and female (n = 500) prisoners in the US, McClellan, Farabee, and Crouch (1997) found the same gender difference but a lower overall rate of sexual abuse, mistreatment or rape among male (5%) and female (26%) inmates during their childhood. This prevalence rate for males is comparable to that in the general population. In contrast, Johnson et al. (2006) in a study of 100 incarcerated males found that 59% of the men reported some form of contact sexual abuse during childhood. What is interesting about the findings of this study is that most of the men (95%) reported child sexual abuse perpetrated by a female. This finding is not consistent with previous studies of general populations in which the overwhelming majority of perpetrators are male (McCloskey & Raphael, 2005; Peter, 2009). In an extensive review and meta-analysis of the published research relevant to risk-factors for perpetration of child sexual abuse, Whitaker et al. (2008) found a strong relationship in the literature between being a victim of childhood sexual abuse and perpetrating child sexual abuse. Child sex offenders were found to be much more likely to have been victims of child sexual abuse than either non-sex offenders and non-offenders.
It is important to note, however, that these findings indicate that most victims of child sexual abuse do not go on to offend sexually or in other ways, although the risks are higher than for those in the general population who were not sexually abused. Although the Ogloff et al. (2012) study clearly indicated that victims of child sexual abuse are at greater risk of subsequent offending behaviour, most child sexual abuse victims (77%) did not have a criminal record.
7 One problem with this study, though, is that it did not examine gender effects specifically in relation to child sexual abuse only, but rather child abuse and neglect generally (inclusive of child sexual abuse). Although arguably this design characteristic limits the conclusions that may be drawn, in fact, it more accurately reflects the reality of co-occurrence of multiple types of child maltreatment and abuse (Pears, Kim, & Fisher, 2008).