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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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