Child sexual abuse is widely regarded as a cause of mental health problems in adult life. This article examines the impact of child sexual abuse on social, sexual and interpersonal functioning, and its potential role in mediating the more widely recognised impacts on mental health. In discussing the relationship between child sexual abuse and adult psychopathology, the authors evaluate a number of models, including the post-traumatic stress disorder model, the traumatogenic model, and developmental and social models. They look at family risk factors which predispose children from specific population groups to be at greater risk of abuse, and conclude that the fundamental damage caused by child sexual abuse impacts on the child's developing capacities for trust, intimacy, agency and sexuality.

Contents

• Early research
• Implications
• Post-traumatic stress model
• Traumatogenic model
• Dangers of post-traumatic stress model
• Family risk factors
• Abuse overlap
• Victim characteristics
• Interpreting correlation studies
• Socioeconomic status
• Sexuality and sexual adjustment
• Relationships and intimacy
• Self-esteem
• Long-term impact on mental health
• Alcohol abuse
• Unravelling the associations between abuse and long-term problems
• Prevention
• Conclusion
• References

In little over a decade, child sexual abuse has come to be widely regarded as a cause of mental health problems in adult life. The influences of child sexual abuse on interpersonal, social and sexual functioning in adult life and its possible role in mediating some, if not all, of the deleterious effects on mental health, has attracted less attention and research, but is arguably equally important. For this reason, and because the mental health aspects have been so much more widely canvassed and ably reviewed (Tomison 1996), this review will emphasise the impact of child sexual abuse on social and interpersonal functioning, and its potential role in mediating the more widely recognised impacts on mental health.

Early research

The manner in which the long-term effects of child sexual abuse have come to be conceptualised reflects, in no small measure, the very particular circumstances that surrounded the revelation of child sexual abuse as an all too common event in the lives of our children. The first phase of modern research into child sexual abuse was not triggered by observations on child victims, but by the self-disclosures of adults who had the courage to publicly give witness to their abuse as children. These early self-revealed victims, exclusively women, had often been the victims of incestuous abuse of the grossest kind, and plausibly attributed many of their current personal difficulties to their sexual abuse as children. This contrasts with the emergence of child abuse as a public health and research issue that has been driven by the observations of professionals caring for abused children.

Implications

The way child sexual abuse was placed on the public and health agendas put a stronger emphasis on the adult consequences of abuse than on the immediate implications for an abused child. It also emphasised the psychiatric implications of abuse because self-declared victims tended to focus on these, and these revelations often occurred in a broadly therapeutic context with mental health professionals. Early research into the effects of child sexual abuse frequently employed groups of adult psychiatric patients (Carmen et al. 1984; Mills et al. 1984; Bryer et al. 1987; Jacobson and Richardson 1987; Craine et al. 1988; Oppenheimer et al. 1985) which further reinforced the emergence of an adult-focused psychiatric discourse about child sexual abuse. It should also be noted that the manner in which child sexual abuse was rediscovered (for it had been well recognised in the 19th century) and the nature of the advocacy movement which placed child sexual abuse firmly on the social agenda also provided an almost exclusive emphasis on female victims and incestuous abuse. The implications remain largely unexplored of the abuse of boys (which for abuse of the most intrusive kinds involving penetration rivals in frequency that of girls), and of the fact that the majority of abuse is not incestuous.

Post-traumatic stress model

The relationship between child sexual abuse and adult psychopathology tended initially to be conceptualised in terms of a chronic form of post traumatic stress disorder (Lindberg and Distad 1985; Bryer et al. 1987; Craine et al. 1988). This model focused on trauma-induced symptoms, most particularly dissociative disorders such as desensitisation, amnesias, fugues and even multiple personality. The idea was that the stress induced symptoms engendered in the process of the abuse and have reverberated down the years to produce a post-abuse syndrome in adult life.

In its more sophisticated formulation, this model attempts to integrate the damage inflicted at the time to the victims' psychological integrity, by the child sexual abuse and the need to repress the trauma, with resultant psychological fragmentation. The latter manifests itself in adult life in mental health problems, and in problems of interpersonal and sexual adjustment (Rieker and Carmen 1986). The post-traumatic stress model found its strongest support in the observations of clinicians dealing with individuals with histories of severe and repeated abuse. It was also often linked to notions of a highly specific post-abuse syndrome in which dissociative disorders were prominent.

Traumatogenic model

In the United States, a less medicalised model for the mediation of the long term effects of child sexual abuse was proposed by Finkelhor (1987) with his 'traumatogenic model'. This suggested that child sexual abuse produced a range of psychological effects at the time and, secondarily, behavioral changes. This model predicts a disparate range of psychological impairments and behavioral disturbances in adult life which contrasts with the post traumatic syndrome model with its specific range of symptoms. Finkelhor's model, though less medical and symptom-bound, pays only scant attention to the developmental perspective. It cedes primacy to the psychological ramifications of the abuse with little acknowledgment of the social dimensions. Only in recent years have attempts been made to articulate the long-term effects of child sexual abuse within a developmental perspective (Cole and Putnam 1992), and to attend to the interactions between child sexual abuse and the child victims' overall psychological, social and interpersonal development.

Dangers of post-traumatic stress model

The belief that child sexual abuse is not only a potent cause of adult psychopathology but can be understood and treated within a post-traumatic stress disorder framework has spawned a minor industry in sexual abuse counselling. Though many working in this area have shifted, on the basis of their clinical experience, to broader conceptualisations, there remains a considerable vested interest in a specific post-abuse syndrome.

There are also political agendas linked to seeing child sexual abuse as a product of misdirected and ill controlled male sexuality (which it is), and as independent of social circumstances and family background (which it isn't). Herman's (1992) description of child sexual abuse as one of the combat neurosis women suffer from as a result of the sex war neatly conflates the post-traumatic stress model with the political agenda of some feminists.

The understandable wish to avoid repeating the deplorable error made in domestic violence of blaming the victim (Snell et al. 1964) can lead to an insistence on looking no further than the perpetrator (and often just his maleness) for an understanding of why abuse occurs. This potentially impoverishes research aimed at identifying the social and family correlates of child sexual abuse that constitute risk factors for such abuse. The knowledge of such risk factors is essential to the development of programs aimed at primary prevention.

Family risk factors

Child sexual abuse is not randomly distributed through the population. It occurs more frequently in children from socially deprived and disorganised family backgrounds (Finkelhor and Baron 1986; Beitchman et al. 1991; Russell 1986; Peters 1988; Mullen et al. 1993). Marital dysfunction, as evidenced by parental separation and domestic violence, is associated with higher risks of child sexual abuse, and involves intrafamilial and extrafamilial perpetrators (Mullen et al 1996; Fergusson et al. 1996; Fleming et al. 1997).

Similarly, there are increased risks of abuse with a stepparent in the family, and when family breakdown results in institutional or foster care. Poor parent­-child attachment is associated with increased risk of child sexual abuse, though it is not always easy to separate the impact of abuse on intimate family relationships from the influence of poor attachments on vulnerability to abuse (Fergusson et al. 1996; Fleming et al. 1997).

Disrupted family function could, in theory, be related to child sexual abuse because of the disruptive influence of a perpetrator in the family. However, given the majority of abusers are not immediate family members, it is more likely that the linkage reflects a lack of adequate care, supervision and protection that leaves the child exposed to the approaches of molesters, and vulnerable to offers of apparent interest and affection (Fergusson and Mullen in press).

Abuse overlap

There is also a considerable overlap between physical, emotional and sexual abuse, and children who are subject to one form of abuse are significantly more likely to suffer other forms of abuse (Briere and Runtz 1990; Bifulco et al. 1991; Mullen et al. 1996; Fergusson et al. 1997; Fleming et al. 1997). Mullen and colleagues (1996) found women with histories of child sexual abuse had over five times the rate of physical abuse, and were three times as likely to also report emotional deprivation.

It could be that family circumstances conducive to child sexual abuse are also productive of other forms of abuse. This hypothesis is supported by the clear overlap between the risk factors for all three types of abuse. The second possibility is that the apparent comorbidity could reflect a data collection artefact created by individuals who are prepared to disclose one type of abuse being prepared to disclose other forms of abuse (Fergusson and Mullen in press).

Victim characteristics

The possibility has been raised that characteristics such as physical attractiveness, temperament or physical maturity might increase the risks of children being sexually abused (Finkelhor and Baron 1986). Child molesters are reported to selectively target pretty and trusting children (Elliot et al. 1995). A recent study suggested early sexual maturation in girls may be associated with increased vulnerability to abuse (Fergusson et al. in press). Fleming et al. (1997) reported girls who were socially isolated with few friends of their own age were almost twice as likely to report having been sexually abused.

Interpreting correlation studies

The tendency for child sexual abuse to co-vary with disturbed family backgrounds, other forms of abuse and possibly even victim characteristics, creates profound difficulties when it comes to interpreting correlational studies. This is particularly the case when examining long-term deleterious effects that could theoretically result from child sexual abuse itself, or from those other childhood traumas and disadvantages with which it is so often associated.

In some cases, the adverse outcomes attributed to child sexual abuse may be related as much to the disrupted childhood backgrounds, in the context of which the abuse arose, as to the child sexual abuse itself. There are reports that poor family functioning may account for many of the apparent associations between a history of child sexual abuse and adult psychopathology (Fromuth 1986; Conte and Schueman 1987; Friedrich et al. 1987; Wyatt and Mickey 1987; Harter et al. 1988).

Mullen et al. (1993) in a study on New Zealand women found positive correlations between a history of child sexual abuse and mental health problems in adult life. However, the overlap between the possible effects of child sexual abuse and the effects of the matrix of disadvantage from which abuse so often emerges was so considerable as to raise doubts about how often, in practice, child sexual abuse could operate as an independent causal element.

When examining all subjects with histories of child sexual abuse, it was found that the risks of women victims, who came from stable and satisfactory home backgrounds, developing significant adult psychopathology were no higher than for non-abused controls from similar backgrounds. This did not, however, hold for those who gave histories of the most physically intrusive forms of abuse involving actual penetration. This group, which contained a significant proportion of women subjected to chronic penetrative abuse in an incestuous context, did have significant increases in psychopathology, even when account was taken of the confounding influence of disrupted and disorganised family and social backgrounds.

Fleming et al. (in press), in a study of Australian women, found mental health problems to be associated with a history of child sexual abuse. However, when a multivariate analysis taking into account social and family background variables was employed, it was again only in those whose abuse had involved penetration that the association remained significant.

These findings go some way to reconciling the observations of clinicians who discern clear and dramatic relationships in their patients between prior child sexual abuse and current symptoms of specific mental disorders, and epidemiologists who extract from their data less specific correlations that barely survive confrontation with confounding variables.

The clinician sees, almost exclusively, the most severely abused whereas the epidemiologist studies the full range of reported child sexual abuse in a community. The clinician extrapolates from the individual case where dramatic personal experiences like child sexual abuse inevitably seem to explain the occurrence of disorder (particularly when patient and therapist start from the assumption that child sexual abuse deserves primacy), whereas the epidemiologist studying differences in incidence of disorders in a population is drawn to broad sociocultural and environmental influences that explain the bulk of the variation in populations.

Both perspectives have their place, and with that place comes limitation. Clinicians who, on the basis of experiences with individual cases, seek to describe the role of the full range of child sexual abuse in generating disorder and disease in our community are likely to fall into error, just as epidemiologists fall into error when they attempt to deny any reality, or therapeutic benefits, to the meaningful connections constructed between child sexual abuse and current difficulties in a treatment process.

Socioeconomic status

The possible influence of child sexual abuse on adult social and economic functioning has not received the attention it perhaps deserves. The well documented difficulties that sexually abused children experience in the school situation with academic performance and behaviour (Tong et al. 1987; Cohen and Mannarino 1988; Einbender and Friederch 1989) might be expected to negatively influence later educational attainments, and impair the development of the skills and discipline necessary to sustain effective work roles.

Bagley and Ramsey (1986) noted that those with histories of child sexual abuse tended to have lower status economic roles. A random community sample found women reporting child sexual abuse were more likely to have work histories that placed them in the lowest socioeconomic status categories. (Mullen et al 1994). They were also more likely to have partners whose occupations fell into the lowest socioeconomic groups. This did not simply reflect women with histories of child sexual abuse coming from lower socioeconomic status homes (which they did) but was also a product of a significant decline in socioeconomic status among those reporting child sexual abuse from their family of origin.

This relative decline in socioeconomic status was most marked for women reporting the more severely physically intrusive forms of abuse involving penetration. This latter group had an odds ratio of over four for such a decline, even following a logistic regression that took into account the confounding influences of family background, social disadvantage and concurrent physical and emotional abuse.

Interestingly, this decline in socioeconomic status could not be accounted for by simple educational failure, nor was the decline to be explained by a reduced participation in the workforce, or preference for part-time work. The explanation for abused women being in less well paid and prestigious jobs could be that they underestimated their value and sought occupations below their capacities (a failure of self-esteem), or that they were less adept at translating training and opportunity into effective function in the work sphere (a failure of agency). The increased frequency with which those reporting child sexual abuse entered partnerships with men from lower social classes compounded the tendency to decline in socioeconomic status.

This greater chance of a drop in socioeconomic status relative to family of origin is a crude measure of social and economic failure, and suggests a wide ranging disruption of function that is particularly marked in those reporting the more severe abuse experiences.

Sexuality and sexual adjustment

A history of child sexual abuse has been found to be associated with problems with sexual adjustment in adult life (Herman 1981; Finkelhor 1979). Finkelhor (1984) described what he termed reduced sexual esteem in both men and women who had reported child sexual abuse. In a subsequent study, Finkelhor et al. (1989) found that women who reported child sexual abuse involving intercourse were significantly less likely to find their adult sexual relationships very satisfactory.

An attempt to replicate these findings found no relationship between histories of child sexual abuse and sexual self-esteem, whether in male or female subjects (Fromuth 1986), although there was a suggestion that sexually abused women experienced a wider range of sexual activity and were more sexually active than the non-abused. Greenwald et al. (1990), in a questionnaire study, also failed to establish any significant increase in sexual dissatisfaction or sexual dysfunction in their women reporting child sexual abuse, although they only used a broad definition of abuse and did not analyse their data regarding those reporting penetrative abuse. They concluded that the 'majority of existing evidence seems to suggest that adult sexual functioning is not significantly impaired in community samples of former female victims of childhood sexual abuse who are not seeking treatment'.

In a study of a random community sample of 2,250 New Zealand women with a questionnaire and an interview phase, data was gathered on sexual histories including levels of sexual satisfaction and experienced sexual problems (Mullen et al 1994). The average age at which consensual intercourse first occurred, and the frequency of consensual intercourse with peers prior to reaching the age of 16 years, did not differ between controls and those reporting child sexual abuse. When, however, only those reporting child sexual abuse involving penetration were considered, they were significantly more likely to report consensual intercourse with peers prior to 16 years of age.

The controls and those reporting child sexual abuse were equally likely to have been sexually active in the six months prior to interview, but child sexual abuse victims expressed significantly greater dissatisfaction with the frequency of intercourse, interestingly being more likely to complain of infrequency or an unwelcome frequency. Those with histories of child sexual abuse were nearly twice as likely to report current sexual problems (28 per cent compared with 47 per cent) and for women whose abuse involved penetration, nearly 70 per cent complained of current sexual problems.

The general level of satisfaction with their sex lives was markedly reduced in those with histories of child sexual abuse compared to controls, an unadjusted odds ratio of 9.4 for overall dissatisfaction with their sex lives that rose to over 12 for abuse involving intercourse. Employing similar questions to those used by Finkelhor (1984) to quantify sexual self-esteem, it was found that significantly more child sexual abuse victims believed their attitudes and feelings about sex caused problems or disrupted their satisfaction in sexual relationships.

The unease about their own sexuality was most common in those whose reported abuse had involved penetration. There was also a significant increase in the frequency with which the victims complained of what they perceived as negative and disruptive attitudes in their partners that caused sexual difficulties. Fleming et al. (in press) in a community sample of Australian women found that child sexual abuse involving penetration was a significant predictor of sexual problems in adult life, even after taking the family and social backgrounds of the victims into account.

In the study by Mullen et al. (1994), there was also evidence for an association between a history of child sexual abuse and an earlier age of entering the first cohabitation and an earlier age at first pregnancy. This precocious involvement in an attempt at a permanent union and starting a family was particularly marked for those who had been victims of abuse involving penetration. This association could reflect a search for love and affection away from the inadequate home environment that so often accompanies the more severe forms of child sexual abuse. Sadly, in those who had been victims of the more intrusive forms of child sexual abuse, their attempts to establish relationships and families were likely to founder.

There is also evidence that women who report child sexual abuse are at greater risk during adolescence of sexually transmitted diseases, teenage pregnancy, multiple sexual partnerships, and sexual revictimisation (Gorcey et al. 1986; Nagy et al. 1995; Russell 1986; Spring and Friedrich 1992; Fergusson et al. 1997). In an Australian study, Fleming et al. (in press) found that child sexual abuse, in particular abuse involving penetration, was associated with increased risks of being raped as an adult and of being the victim of domestic violence.

These findings support the hypothesis that the exposure of children to the sexual advances and acts of adults places the victim at risk of later sexual problems. The more extreme and persistent forms of abuse produce greater disruption of the child's developing sexuality. The age at which the abuse occurs might be expected to influence the extent of the long-term damage, and child sexual abuse occurring during the pre-pubertal stages of development is perhaps particularly likely to be traumatic. Currently, there are no adequate data on this relationship between age at abuse and subsequent sexual problems.

On the basis of clinical observations, it has been suggested that women exposed to child sexual abuse may in early adult life respond by heightened anxiety about sexual contact (with avoidance of relationships), or a paradoxical promiscuity (in which the victim devalues herself and her sexuality). What constitutes promiscuity tends to be a highly subjective evaluation, and women with a history of child sexual abuse are more ready to respond judgmentally about their prior sexual behaviour by labelling it promiscuous than would non-abused woman with a similar range of sexual experiences. This reflects not changed sexual behaviour, but changed attitudes to one's own sexuality.

However, there is evidence that in those whose abuse has been particularly gross (in terms of physical intrusiveness, frequency, duration or closeness of relationship to abuser), there is an increased risk of precocious sexual activity with its attendant risks of teenage pregnancy and social ostracism. It would be surprising if the traumatic introduction to sexual activity constituted by child sexual abuse did not place the child's sexual development in some degree of jeopardy. Studies such as those of Fromuth (1986) and Greenwald et al. (1990) that did not detect any negative long-term effects of child sexual abuse on adult sexuality probably had samples lacking a sufficient number of those exposed to more seriously intrusive abuse and, by their methods of analysis, the damage inflicted by the more severe forms of abuse was diluted with results from subjects reporting inherently less traumatic abuse experiences.

Women in a random community sample who had reported child sexual abuse were asked what problems they attributed to this abuse. They volunteered sexual problems in nearly 20 per cent of cases, and less than 3 per cent added a belief that they had behaved in an unduly promiscuous manner as adolescents in consequence of the abuse (Mullen et al. 1994). Over 50 per cent of the victims of incestuous abuse in this sample regarded the child sexual abuse as having affected their sexual adjustment as adults. This contrasts with only 5 per cent who attributed mental health problems in adult life to their histories of child sexual abuse.

Similarly, in an Australian study (full reference needed), 17 per cent of those who reported child sexual abuse, when asked whether the abuse had had any long-term effects, reported they believed it had damaged their sexual lives. These self-evaluations certainly underestimate the actual impact of child sexual abuse on the levels of psychopathology, but emphasise the extent to which child sexual abuse is regarded by victims as disrupting subsequent sexual development.

The sexual problems reported so frequently in those subjected to child sexual abuse, particularly of the more chronic and physically intrusive types, may be conceptualised in terms of the disruption of the developing child's construction of sexuality and the nature of sexual activity. Child sexual abuse may well create for some victims a construction of sexual intimacy contaminated by exploitation and coercion. The lack of mutuality and benevolence implicit in a child being used as the object of an adult's sexual acts is a disastrous introduction to the possibility of loving sexual relationships. That experiences of sexual abuse, particularly when repeated or when involving a breach of what should be a caring and protecting relationship, leave no residual damage seems an inherently unlikely proposition.

Relationships and intimacy

The sexual problems linked to child sexual abuse could be an entirely specific effect related to traumatic sexualisation, or could be contributed to by a wider constellation of disruption of interpersonal and intimate relatedness. Child sexual abuse involves a breach of trust or an exploitation of vulnerability, and frequently both.

Sexually abused children not only face an assault on their developing sense of their sexual identity, but a blow to their construction of the world as a safe enough environment and their developing sense of others as trustworthy. In those abused by someone with whom they had a close relationship, the impact is likely to be all the more profound. A history of child sexual abuse is reported to be associated in adult life with insecure and disorganised attachments (Alexander 1993; Briere and Runtz 1988; Jehu 1989). Increased rates of relationship breakdown have also been reported in those exposed to child sexual abuse (Beitchman et al. 1991; Bagley and Ramsey 1986; Mullen et al. 1988).

Mullen et al. (1994) found that their subjects reporting child sexual abuse were more likely to evince a general instability in their close relationships. Though those with histories of child sexual abuse were just as likely as controls to be currently in a close relationship, they were more likely in the past to have experienced divorce or separation. When asked about the level of satisfaction with their current relationship, those with abuse histories expressed significantly lower levels of satisfaction. The level of current satisfaction was lowest for intercourse victims.

Relationship problems were also reflected in the evaluations of the quality of their communication with their partners. Less than half of the victims felt able to confide personal problems to their partner, and nearly a quarter reported no meaningful communication with their partners on a more intimate level, whereas only 6 per cent of controls took an equally negative view of their partners receptivity to their concerns. This perceived gap in communication at a deeper level rose to 36 per cent in those reporting child sexual abuse involving penetration.

In this study, those reporting child sexual abuse were more likely to rate their partners as low on care and concern, and high on intrusive control. Interestingly, the deficiencies perceived in their partners as sources of emotional support by those with histories of child sexual abuse was not generalised to peer relationships where they were just as likely to report they had friends in whom to confide and with whom to share their troubles.

A community study of Australian women found similar results with a history of child sexual abuse adversely affecting the quality of women's relationships in adult life, and increasing the likelihood of divorce and separation (Fleming, 1997, Fleming et al, in press). Women who reported a history of child sexual abuse were more likely to report their current partner to be uncaring and highly controlling, and to be dissatisfied with the relationship. Child sexual abuse appears to affect a woman's ability to maintain intimate relationships by interfering with her capacity to develop her sexuality and trust in others. The results of this study also found that women with histories of child sexual abuse who found difficulty in forming satisfying intimate relationships did not, however, report an inability to form close friendships or to receive emotional support from friends.

It is tempting to suggest that the experience of child sexual abuse at a vulnerable moment in the child's development of trust in others predisposes to a specific deficit in forming and maintaining intimate relationships. The attribution of a lack of concern and a tendency to be intrusive and overcontrolling to their partners could be a product of these partners' actual attitudes and behaviour, or could reflect primarily the expectations, interpretations and projections directed at the partner by these women with histories of child sexual abuse. Conversely, those who have been abused may be more prone to enter relationships with emotionally detached and domineering partners because their lowered self-esteem and reduced initiative limits their choices, or from some neurotic compulsion to repeat.

Self-esteem

Self-esteem encompasses the extent to which individuals feel comfortable with the sense they have of themselves (the self for self) and, to a lesser extent, their accomplishments, and how they believe they are viewed by others (the self for others). Robson (1988) wrote that self-esteem is 'the sense of contentment and self acceptance that stems from a person's appraisal of his (or her) own worth, significance, attractiveness, competence and ability to satisfy aspirations'.

A number of studies have implicated child sexual abuse in lowering self esteem in adults (for review, see Beitchman et al. 1992), but the most sophisticated examination of the issue to date is that of Romans et al. (1996). This study showed a clear relationship between poor self-esteem in adulthood and a history of child sexual abuse in those who reported the more intrusive forms of abuse involving penetration. It was, however, those aspects of self-esteem involved with an increased expectation of unpleasant events (pessimism) and a sense of inability to influence external events (fatalism) that were affected, not those involved with a sense of being attractive, having determination, or being able to relate to others.

Long-term impact on mental health

There have been numerous studies examining the association between a history of child sexual abuse and mental health problems in adult life that have employed clinical samples, convenience samples (usually of students), and random community samples. There is now an established body of knowledge clearly linking a history of child sexual abuse with higher rates in adult life of depressive symptoms, anxiety symptoms, substance abuse disorders, eating disorders and post-traumatic stress disorders (Briere and Runtz 1988; Winfield et al. 1990; Bushnell et al. 1992; Mullen et al. 1993; Romans et al. 1995 and 1997; Fergusson et al. 1996; Silverman et al. 1996; Fleming et al. in press). A more controversial literature links multiple personality disorder with child sexual abuse (Bucky and Dallenberg 1992; Spanos 1996).

Space does not allow a full review of the complex relationships between adult psychopathology and child sexual abuse but to illustrate the trajectory followed by such research in recent years, the literature relating a history of child sexual abuse to alcohol abuse in adult life will be briefly considered.

Alcohol abuse

Research into the relationship between child sexual abuse and alcohol abuse began with reports that clients with substance abuse problems reported high levels of exposure to child sexual abuse. A review of 12 studies conducted prior to 1995 indicated that the rates of child sexual abuse among those in treatment for alcohol abuse varied from as high as 84 per cent to as low as 20 per cent (Fleming et al. in press (b)).

Other evidence suggesting a relationship between child sexual abuse and alcohol abuse came from studies of women with histories of child sexual abuse who were attending treatment for mental health problems. These studies generally found higher rates of alcohol abuse in women with a history of child sexual abuse (Pribor and Dinwiddie 1992; Swett and Halpert 1994).

Recent research into the relationship between child sexual abuse and alcohol abuse has been methodologically more sophisticated than in the past, and has used community samples with larger sample sizes, random samples and more adequate definitions for both alcohol abuse and child sexual abuse (Peters 1988; Bushnell et al. 1992; Fergusson et al. 1996). However, conflicting results on the possible linkage between child sexual abuse and alcohol abuse have been reported. This has given rise to doubt about the strength of an association, the extent to which this relationship reflects a causal connection, and how any connection is mediated and influenced by other aspects of background and development.

The link between child sexual abuse and alcohol abuse may not be a simple causal chain. Fleming et al. (in press, (b)) in a case-control study examining the relationship between a reported history of child sexual abuse and the development of alcohol abuse in a sample of 710 Australian women, proposed that a history of child sexual abuse was not, by itself, sufficient to cause alcohol dependency in women. The relationship between child sexual abuse and alcohol abuse more likely reflects a complex interplay between child sexual abuse and a range of other factors in a woman's life. Their results showed that in combination with the perception of a mother who was uncaring and overly controlling, being sexually abused did increase the risk of alcohol abuse in women. These results also suggest evidence for protective effects such that the perception of having a kind, caring and loving mother may help overcome some of the potentially adverse effects of child sexual abuse on subsequent vulnerability to alcohol abuse.

The proposition that the long-term effects of child sexual abuse may be modified by an individual's experience subsequent to the abuse has also been suggested. Romans et al. (1995 and 1997) demonstrated that long-term problems following child sexual abuse were significantly lower in those who had supportive and confiding relationships with their mothers. In addition, in adults with a history of child sexual abuse, a three-way interaction was found between child sexual abuse, having an alcoholic partner, and having high expectancies of alcohol as a sexual disinhibitor.

The research on child sexual abuse and alcohol abuse illustrates the complexity of the interactions between abuse and the emergence of adult problems. As a minimum, there are interactions between the severity of the abuse, the family relationships prior and subsequent to the abuse, the adult victims' preconceptions about alcohol reducing sexual anxieties and, finally, the drinking habits of their eventual partner. Even this list fails to convey the complexity of the dynamic interactions between development, abuse and family and social experiences. This is not complexity for the sake of complexity. Understanding the impact of child sexual abuse in a developmental and interactive perspective is central to effective therapy for adults and child victims, and for secondary prevention strategies.

Unravelling the associations between abuse and long-term problems

There is a wide range of potential adverse adult outcomes associated with child sexual abuse. However, there is no unique pattern to these long-term effects and no discernible specific post-abuse syndrome. This suggests that child sexual abuse is best viewed as a risk factor for a wide range of subsequent problems.

In studies on the long-term impact of child sexual abuse that employ adult subjects, it is all too easy to forget the abuse occurred in childhood, and to resort to applying inappropriately adult-centred conceptualisations. In deriving models of the link between child sexual abuse and adult difficulties, the heavy reliance on the concept of post-traumatic stress disorder may be an example of such an error.

The sexual abuse of children occurs during a period in life where complex and, hopefully, ordered changes are occurring in the child's physical, psychological and social being. The state of flux leaves the child vulnerable to sustaining damage that will retard, pervert or prevent the normal developmental processes. The impact of abuse is likely to be modified by the developmental stage at which it occurs. It will also vary according to how resilient the child is in terms of their psychological and social development up to that point. A child who has already had to cope with, for example, a problematic family background or prior emotional abuse, will be more vulnerable to the additional blow of child sexual abuse. A child from a more secure and privileged background may well be equally distressed at the time by the abuse, but is likely to sustain less long-term developmental damage.

These suppositions are born out by studies that have demonstrated powerful interactions between the child's prior exposure to potentially damaging situations, and the degree of adult disturbance apparently associated with a history of child sexual abuse (Mullen et al. 1993 and 1994; Fergusson et al. 1996 and 1997).

The long-term effects of child sexual abuse will also be modified by the individual's experience subsequent to the abuse. Romans et al. (1995 and 1997) demonstrated that long-term problems following child sexual abuse were significantly lower in those who had supportive and confiding relationships with their mothers and in those who, as adolescents, experienced some success at school or with peers. The nature of this success (academic, social or sporting), is probably less important than the accompanying strengthening of self-esteem and enhancement of opportunities for effective social interactions with peers.

The relationship between the potential damage inflicted on elements in the child's development and subsequent mitigating factors is, of necessity, complex. For example, the observation that those victims of child sexual abuse who manage to establish and maintain stable marital relationships are protected against some of the potentially adverse outcomes of child sexual abuse (Cole et al. 1992) may reflect, in part, the mitigating and healing influence of effective intimacy. However, equally, the association may be a product of the ability of those, who have for other reasons avoided the worst effects of child sexual abuse, to enter and sustain intimate relationships.

Peters (1988) suggested that child sexual abuse interacts with family background to produce disruption of the child's developing self-esteem and sense of mastery of the world (agency). It is these deficits, in turn, that increase the likelihood of psychological problems in later life. This model of developmental deficits leading to social and personal vulnerabilities in adult life, which in their turn create an increased risk of mental health problems, can usefully be expanded.

Those with histories of child sexual abuse, particularly of the more physically intrusive types, have an increased risk of social, interpersonal and sexual problems in adult life. This association may play a role in mediating at least some of the far better known associations between child sexual abuse and mental health problems.

Greater vulnerability to depression is found in women who lack an intimate and confiding relationship (Henderson and Brown 1988; Harris 1988; Romans et al. 1992). Depression is also associated with lowered self-esteem and a sense of hopelessness about one's ability to influence one's life (Browne et al. 1986, Ingram et al. 1986). Thus the social, interpersonal and sexual problems associated with a history of child sexual abuse may themselves provide fertile ground for the development of mental health problems, particularly in the area of depressive disorders.

A plausible hypothesis can be advanced that the developmental disruption engendered by child sexual abuse in the victims' sense of self-esteem, sense of agency, sense of the world as a safe enough environment, in their capacity for entering trusting intimate relationships and, finally, in their developing sexuality, leads in adult life to an increased risk of low self-esteem, social and economic failure, social insecurity and isolation, difficulties with intimacy and sexual problems.

This constellation of difficulty is a pattern of disadvantage likely to leave the subject prone to depressive and anxiety disorders. The vulnerability may be expressed if, and when, the subject encounters psychosocial or physical stressors, particularly if those stressors target specific areas of developmental vulnerability. (See Figure 1)

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Prevention

The ideal response to child sexual abuse would be primary prevention strategies aimed at eliminating, or at least reducing, the sexual abuse of children (Tomison, 1995). This review has, however, focused on issues related to the deleterious outcomes linked to child sexual abuse rather than on the characteristics of abusers and the contexts in which abuse is more likely to occur, which are relevant to primary prevention. From the information presented here, the implications are for secondary and tertiary preventive strategies aimed at ameliorating the damage inflicted by abuse, and reducing the subsequent reverberations of that damage.

Child sexual abuse may be a necessary, but rarely (if ever) a sufficient, cause of adult problems. Child sexual abuse acts in concert with other developmental experiences to leave the growing child with areas of vulnerability. This is a dynamic process at every level, and one in which there are few irremediable absolutes. Abuse is not destiny. It is damaging, and that damage, if not always reparable, is open to amelioration and limitation.

Those who have been abused who subsequently have positive school experiences where they feel themselves to have succeeded academically, socially or at sport, have significantly lower rates of adult difficulties (Romans et al. 1995). Those whose relationship with their parents subsequent to abuse was positive and supportive fared better, and a good relationship with the father appeared to have a strong protective influence regarding subsequent psychopathology (Romans et al. 1995). Even aspects of the parental figures' relationship to each other seem to have an influence. Expressions of physical affection between parents was associated with better outcomes, and marked domestic disharmony, particularly if associated with violence, added to the damage (Romans et al. 1995; Spaccarelli and Kim 1995). Finally, those who can establish stable and satisfactory intimate relationships as adults have significantly better outcomes.

There is no reason why a well-organised and funded school system should not provide all children with a positive experience academically, socially or in sport. There is no need to identify and target abuse victims, but simply to make every effort to ensure adolescents have the opportunity to share in the enhanced social opportunities, the increased mastery, and the pleasure of achievement that school should provide at some level to all.

The encouragement of sport may seem trivial, but it has a protective influence on psychiatric disorders in all adolescents, not just those with histories of child abuse (Romans et al. 1996; Thorlindsson et al. 1990; Simonsick 1991). Similarly in adult life, success in tertiary education and in the workforce is associated with reduced vulnerability to psychiatric problems for the abused and the non-abused alike, but particularly for the abused (Romans et al. 1996).

The secondary preventive strategies of relevance in reducing the impact of child sexual abuse are equally relevant to reducing a wide range of adolescent and adult problems unrelated to abuse. These include improved parental relationships, reduced domestic violence and disharmony, improved school opportunities, work opportunities, better social networks, and better intimate relationships as adults. The list is so familiar as to be platitudinous, but is nonetheless of central importance.

The model advanced in this paper is of child sexual abuse contributing to developmental disruptions that lay the basis for interpersonal and social problems in adult life. These, in turn, increase the risks of adult psychiatric problems and disorders. If this is correct, then focusing on improving the social and interpersonal difficulties of those with histories of child sexual abuse may be the most effective manner of reducing subsequent psychiatric disorder.

This argues for tertiary prevention strategies aimed at improving self-esteem, encouraging more effective action in work and recreational pursuits, attempting to overcome sexual difficulties, and working specifically on improving the victim's social networks and capacities to trust in, and accept, intimacy. This does not imply that established affective disorders or eating disorders should not be treated in their own right, but suggests that focusing on current vulnerabilities and deficits may be more productive than extended archeologies of past abuse in the search of an elusive retrospective mastery.

Conclusion

The hypothesis advanced in this paper is that, in most cases, the fundamental damage inflicted by child sexual abuse is to the child's developing capacities for trust, intimacy, agency and sexuality, and that many of the mental health problems of adult life associated with histories of child sexual abuse are second-order effects. This hypothesis runs counter to the post-traumatic stress disorder model, and suggests different therapeutic strategies and strategies of secondary prevention.

In practice, both models may be of value. The post-traumatic stress disorder like mechanisms may predominate in the short term, and in those who have been exposed to the grossest form of child sexual abuse. The developmental and social model may carry the weight of causality in the far commoner, but less utterly overwhelming, forms of child sexual abuse.

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