| 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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