A Review Of The Long-Term Effects Of Childhood Sexual Abuse

The Long-Term Outcomes of Childhood Sexual Abuse

Abstract

This paper reviews the long-term effects of childhood sexual abuse in light of the 1998 meta-analysis by Rind et al. which found that CSA does not produce severe long-term effects on psychopathology. Evidence is offered to the contrary, specifically as it relates to factors such as self-harm, revictimization, and risky sexual behavior. Despite the sweeping claims offered by many researchers in the field, this paper asserts that the literature on the impact of CSA on adults is limited in several crucial ways. Lastly, a potential future study that can help explore the differences between college and non- college samples of CSA survivors is proposed.

Of the many problems faced by children and adolescents, few provoke such moral outrage as childhood sexual abuse. Many times, as on the television show To Catch a

Predator, such abuse can be inflicted by strangers who may gradually become familiar with the child online. Sadly, however, often times the perpetrator of sexual abuse on children is someone much more familiar to the child- someone the child may even love.

Parents, stepparents, siblings, and family friends commonly comprise the list of individuals who sexually abuse children. Given the traumatic nature of this alarmingly common occurrence, it is understandable that many people fear the impact of experiencing childhood sexual abuse. 2

While commonly accepted wisdom had been that childhood sexual abuse resulted in negative lifelong outcomes, a meta-analysis sparked tremendous controversy when it concluded that childhood sexual abuse (CSA) results in mild long-term impairment

(Rind, Tromovitch, & Bauserman, 1998). However, the scientific literature on the subject does appear to represent a mixed bag of conflicting results and dubious studies. While it does seem that specific psychological disorders may not be serious outcomes in some samples of adults and college students who suffered CSA, there may be a long-lasting impact of CSA on some measures such as self-harm, revictimization, and later family outcomes. Still, despite the evidence for some of these trends, the scientific reviews of the topic leave much to be desired.

Method

For the present review paper, a literature search was conducted using PsycInfo as the primary database. The key search terms used included childhood sexual abuse and outcomes, and later sexual abuse or childhood abuse and adjustment. The resulting studies were searched for relevant journal articles. Dissertations and books were not used.

Studies in journals were favored, especially those arising after 1998, the year in which the

Rind et al. meta-analysis was published. Literature found on PsycInfo but which could not be accessed through the database was searched for on Google Scholar. Additionally,

John R. Weisz, Ph.D., Professor of Psychology at Harvard University, with the assistance of Dr. Judy Cohen and her colleague Tony Manarino, provided three articles that have also been used in this review. Some relevant studies were obtained after browsing the reference lists of articles obtained on PsycInfo. 3

Findings

Childhood sexual abuse appears to be an all-too-common experience for children.

One meta-analysis found a prevalence rate of 14% for males and 27% for females (Rind et al., 1998), figures supported in later studies (Dube et al., 2005). While literature on the long-term impact of the trauma is mixed, studies often support immediate psychological disturbances. In one recent study, 20 sexually abused children in Turkey (mean age 9.4 years) were found to be diagnosed with a DSM disorder in 55% of cases and have significantly higher scores of behavioral problems on the Child Behavior Checklist than

Turkish norms (Ozbaran et al., 2009). However, the findings of this study indicate that the immediate impact of CSA does not necessarily persist. Two years later, although abused children still had significantly higher scores on the CBCL than a control population on every measure, 100% of the CSA subjects were without a psychiatric diagnosis. Despite some evidence for resilience, these findings are limited by some of the typical problems associated with CSA research. For one, participants were clinically referred, making them a sample biased toward more unfavorable outcomes. Second, the researchers did not control for treatment of CSA children in the time between first and last assessments.

Still, the 1998 meta-analytic study of the long-term effects of CSA supports the idea that CSA survivors are resilient. Rind et al. (1998) looked at 59 published and unpublished studies to examine the effects of CSA in college samples on 18 measures, including anxiety, depression, and self-esteem. The authors found that on average college students with a CSA history were very slightly less well-adjusted than non-CSA college 4 students (Pearson correlation r = .09). Additionally, they found an average effect of family environment on later psychopathology to be greater than that of CSA (r = .29), and controlling for family environment took away significant effects of CSA in some cases. In short, CSA did not necessarily produce lasting negative effects, at least with regard to psychological problems. However, it may not be representative to look only at

CSA survivors in college. Some studies showed college samples to differ from other samples, while others found no differences. Nevertheless, people in college have several protective factors working in their favor, such as intelligence and often a supportive family, peer, and/or school environment. Looking at other sample populations allows researchers to avoid these biases, but could lead to looking at samples that are biased in other ways.

In trying to understand how CSA might affect some individuals, Trickett and

Putnam (1993) put forth a developmental model of abuse. Focusing on females, the authors argue that, depending to some degree on severity, childhood sexual abuse causes both acute physiological and psychological stress responses. The psychological distress and hormonal changes going on within the child may interact to produce a lesser view of one’s own competence or psychopathology. The effects of the stress are moderated by when in puberty the event takes place and the level of family support. With the changes in the body that occur during puberty and a growing sense of one’s own sexuality, the authors speculate that CSA survivors avoid their distressing sexual feelings and become more at risk for anxiety, poor coping, and submissive behavior. These effects may be most pronounced in later relationships and sexual behavior, but other areas of life can be affected as well. 5

Some research supports the idea that CSA affects individuals in the long run. One large Australian study examined pairs of twins and found that sexually abused female twins had higher rates of depression, suicide, alcohol problems, social anxiety, rape after the age of 18, and divorce than their non-abused co-twins and non-abused controls

(Nelson et al., 2002). Males had similar effects, minus social anxiety and divorce. As predicted by Trickett and Putnam (1993) family support variables seemed to moderate the relationship of CSA and adverse outcomes, as non-abused co-twins were at greater risk than control subjects for later life problems. However, CSA was inferred to play a causal role in that abused individuals had significantly worse outcomes than their non-abused twins. As seems to be the norm of the field, this study is limited in that self-reports were used from a volunteer sample of twins.

The adverse effects of CSA on self-injury and adult relationships are supported elsewhere in the literature as well. One study of retrospective recall (mean participant age

= 56) calculated the odds ratios of various negative adult outcomes and found that self- reported CSA put people at a twofold risk for suicide attempts (Dube et al., 2005). The risk of marrying an alcoholic was 40% greater for CSA than non-CSA participants. These results indicate that CSA can have harmful effects beyond distinct forms of psychopathology. Self-harm is a particularly dangerous outcome, but marrying an alcoholic could have damaging accumulated effects over the course of a marriage. Long- term adult relationships are central to most people’s lives, and yet extremely difficult to study with a college sample.

One study on CSA’s effects on interpersonal relationships seems to indicate that

CSA does mediate adult relationships. Liang, Williams, and Siegel (2006) reported 6 results from a longitudinal study of mostly low-SES, African-American women with documented hospital records of abuse. The use of hospital records may indicate that these women suffered particularly severe abuse, but CSA was still shown to have a significant main effect on marital satisfaction. One interesting addition was that CSA survivors with strong maternal attachments were buffered against the negative effects of CSA. In fact, strong attachment was also correlated with a lower likelihood of getting married or cohabiting. It could be that securely attached women are less likely to anxiously seek out relationships and develop a submissive interpersonal style that leads to less marital satisfaction. However, the findings are severely limited by a lack of a control group, method of assessing CSA, and using mostly low-income (46% less than $14,000 per year) African-American women.

One possible factor that may play into lower marital satisfaction and poor long- term outcomes for relationships is the risk for early pregnancy among female CSA survivors. In a meta-analysis, Noll et al. (2009) calculated an aggregate effect size of odds ratios from 14 studies and found that CSA is correlated with a twofold risk for adolescent pregnancy. One possible reason for this relationship is that the risk factors (i.e. bad family environment) of CSA and adolescent pregnancy are the same. The sexual nature of CSA could distort a child’s perception of appropriate sexual behavior, leading to a more submissive attitude and more willingness to have sex at a young age. It is also possible that immediate physiological reactions to stress might affect later risk-taking, but more evidence is needed for that conclusion.

In addition to adolescent pregnancy, risky sexual behaviors could play into later revictimization of CSA survivors. The Australian twin study (Nelson et al., 2002) found 7 elevated rates of rape after the age of 18 in CSA survivors. However, the exact reasons for this are not clear. Messman-Moore and Long (2003) review the decidedly mixed literature on the subject and speculate that CSA impacts revictimization indirectly. They argue that perhaps some abused women grow up and develop risky sexual behaviors or excessive alcohol use- two conditions that may leave them more vulnerable to being in potentially violent, ambiguous situations. However, it has been hard to untangle the direct effects of CSA from environmental factors that make both CSA and later life victimization more likely.

Regardless, sexual revictimization poses its own problems. One study of the effects of several types of childhood sexual victimization found that CSA survivors who had been revictimized had significantly more lifetime diagnoses of Axis 1 DSM disorders and more lifetime sexual partners than other victims of CSA (Kaltman et al., 2005). The implication of these findings is that perhaps CSA does impact adult psychopathology, but only as mediated by subsequent episodes of sexual abuse. Of course, it would be difficult to draw conclusions as to the degree of influence CSA has on producing these outcomes, given the many variables surrounding later instances of abuse. Unfortunately, even these findings should be met with skepticism, as the sample was obtained by mailing questionnaires. In essence, the sample was a convenience sample of those who took the time to respond.

Conclusions and Future Directions

In general, the literature on childhood sexual abuse reflects often contradictory findings. Many of the findings presented in this review indicate that CSA does not necessarily greatly impact long-term psychological functioning, but rather can impact 8 survivors’ adult relationships, family patterns, likelihood of revictimization, and even susceptibility to self-harm. Unsurprisingly, these effects can be moderated by secure maternal relationships (Liang et al., 2006). The long-term effects of CSA are not straightforward by any means. In a prospective study, Horwitz et al. (2001) found that

CSA had a less direct impact on adverse consequences than stressful life events generally. Does it produce worse psychological functioning that exposes people to risky situations, or are there other variables such as substandard environments that cause both?

Future research needs to clarify how CSA is related to adverse life events.

Nevertheless, conclusions must be qualified by noting that most studies on the subject of CSA suffer an array of methodological problems. One of the most difficult problems within the literature is deciding on an appropriate sample. College samples may be biased in that they represent an inherently higher functioning group with many protective factors. Further, some adverse consequences like adolescent pregnancy may keep many CSA survivors from going to college. However, clinical, hospital, and legally documented samples often are more severe cases that arise because of multiple problems.

There is a natural bias in sampling an already more dysfunctional subset of CSA survivors. Prospective studies ought to be favored over retrospective studies, but the trade-off is that prospective studies use identifiable groups such as hospital and legal cases that may be more severe. Lastly, too few studies examine outcomes other than diagnostic labels and symptom surveys. While several disparate outcomes have been examined here, more studies are needed. This is especially true of areas like medical outcomes, school achievement, and occupational outcomes. 9

My Dream Study

One of the major problems with research into childhood sexual abuse is the reliance on retrospective studies. Particularly in clinical samples, retrospective recall may be biased toward reflecting an overemphasis on disordered patterns of behaviors. In order to study the actual impact of childhood sexual abuse, I would prefer to use a prospective design. However, such a design would be limited in that it would depend upon actually documented cases of abuse, which may be problematic. Nevertheless, I would want to take a group of children known to have been abused and study them as they get older.

Principally, I would want to examine whether this group differs from a control group on several measures that affect life course outcomes. These measures would include assessing at what rate CSA abused individuals go on to college, age at first pregnancy, and occupational outcomes. However, unlike previous studies, I think it would be imperative to use a control group that is well-matched to the CSA group in several respects. For one, they should have a similar SES background. Secondly, I think it would be interesting to make use of several groups. Comparing CSA kids as they grow up to, for example, non-abused kids and physically abused children would show what some of the specific outcomes of sexual abuse are. This type of study would solve the problem of retrospective bias, while also using a controlled design. Most of the prospective studies I looked at failed to use adequate controls, or were in other ways flawed. Naturally, such a study would still be limited because of the nature of obtaining known CSA children (i.e. through the courts or hospitals). 10

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