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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.
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 parentchild 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)
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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