Mullen and Jillian Fleming www. 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 , 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. 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 ; Bryer et al. 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 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 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 , 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 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. 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 ; Beitchman et al. 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 ; Fergusson et al. Similarly, there are increased risks of abuse with a stepparent in the family, and when family breakdown results in institutional or foster care.
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 ; Bifulco et al.
Mullen and colleagues 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 Child molesters are reported to selectively target pretty and trusting children Elliot et al.
A recent study suggested early sexual maturation in girls may be associated with increased vulnerability to abuse Fergusson et al. 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 ; Conte and Schueman ; Friedrich et al. 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.
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.
Bagley and Ramsey 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 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 ; Finkelhor Finkelhor 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. 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 , 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. 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, 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 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.
Employing similar questions to those used by Finkelhor 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. In the study by Mullen et al. 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. In an Australian study, Fleming et al. 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.