Childhood Sexual Abuse Research Paper

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1. Overview Of The Issue

Numerous studies on the prevalence, characteristics, and consequences of childhood sexual abuse (CSA) have been conducted since the 1970s, but deriving conclusions about this literature has been hampered by the wide variability in definitions and methods used across studies. Nonetheless, enough research has accumulated from both clinical and general population studies to support the claim that CSA is significantly correlated with increased risk for various forms of adult psychopathology. There has been disagreement, however, about whether CSA causes adult psychopathology. Since the 1990s, a few studies have been conducted that allow for causal interpretations about the effects of CSA on adult psychopathology.

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The purpose of this research paper is to describe the historical and scientific development of CSA research, from early clinical studies to current studies of the general population. Definitional and methodological issues in CSA research will be discussed, and a review of recent studies that have used powerful methodologies for understanding cause-and-effect relationships will be presented. Finally, some general conclusions about the effects of CSA on adult psychopathology will be provided, and future directions for this research will be suggested.

2. The Historical Development Of Research On Childhood Sexual Abuse

The evolution of CSA research, as discussed below, has followed a three-phase course that roughly parallels the progression of research found in all psychiatric epidemiological research: (a) pioneering publications and numerous clinical studies; (b) studies using nonclinical (general population) samples to estimate prevalence and correlates of CSA; and (c) studies using scientifically rigorous methods that allow for cause-and-effect conclusions about CSA and adult psychopathology.

2.1 Phase 1 Research: Pioneering Publications And Clinical Research

Modern awareness of the prevalence, characteristics, and possible consequences of CSA in the USA can be traced to the late 1970s and early 1980s. During this first phase of modern CSA research, a few pioneering publications, most notably Finkelhor’s Sexually Victimized Children in 1979 and Russell’s Sexual Exploitation: Rape, Child Sexual Abuse, Sexual Harassment in 1984 provided data that indicated CSA occurred frequently to children and adolescents in the USA. Following these works, public attention to CSA was further stimulated by several highly publicized media accounts of CSA, and clinical research increased dramatically. Results from early clinical studies were mostly of women, and indicated a high percentage of women reporting CSA, with many women indicating that the abuse involved family members and or serious abuse (i.e., intercourse CSA). These studies also found that a history of CSA was associated with elevated rates of several psychological problems, including substance abuse, anxiety dis- orders, depression, self-injurious behaviors, and interpersonal functioning deficits. As a result of this increased attention to CSA, dramatic changes in the reporting and verification of CSA occurred in the USA: from 1976 to 1993, there was a 25-fold increase in verified cases of CSA. Although much of the original research on CSA in the 1970s and 1980s was centered on the USA, other countries, including Canada, the UK, and several European nations began or increased research on CSA.

2.2 Phase 2 Research: General Population Studies Of Prevalence And Correlates Of CSA

The second phase of CSA research in the early 1980s addressed a methodological limitation of earlier studies i.e., that most early studies were based on samples of children who were identified as being abused (forensic samples) or samples of adults who were in treatment (clinical samples). These studies were limited because results from forensic and clinical samples may differ significantly from results found among persons who did not report the abuse or who were not in treatment. Numerous nonclinical studies used college samples, but again, women and men in college who report a history of CSA may not generalize to the adult general population for many reasons, including that college students may over-represent socioeconomically advantaged persons and underrepresent psychologically impaired persons. Some researchers have also argued that first-year college students may have very recently experienced CSA, and long-term consequences have not yet occurred.

Forensic, clinical, and college samples studies are quite important for developing a base of research to build upon, but the most scientifically rigorous sampling design is one that uses a random sample from the general population. Random sampling indicates that every person in an identified community or even an entire country has an equal chance of being selected for the study (although random samples may exclude certain age groups or persons living in institutions).

In CSA research, the basic methodology of a general population study is to ask adult participants if they experienced any sexually abusive acts during childhood (the adult retrospective recall method). Researchers also often ask participants to report the characteristics of the abuse (e.g., who was the abuser, the ages of the abuser and participant), any known effects of the abuse, and or any current psychological problems they may be experiencing.

Over 20 adult retrospective studies with general population samples were conducted in North America in the last two decades of the twentieth century, and prevalence rates varied dramatically across studies, with about 2–62 percent in women and 3–16 percent in men. Sources of this variability include differences in (a) definitions of CSA; (b) geographical region of sample; (c) methods of data collection (telephone, mailed, or face-to-face interviews); (d) response rates; and (e) the number of questions used to ask about CSA. Definitions of CSA have varied across all studies to date, primarily in four dimensions: (a) the ages used to delimit childhood (most use 18 or 16); (b) whether or not the respondent is asked to self-define the experience as ‘abusive’ (e.g., asking if the experience was unwanted, the result of force or trickery, and or was considered abusive); (c) whether or not differences in age between the respondent and the perpetrator are used to define CSA; and (d) the types of sexual activities asked about (e.g., contact only acts vs. both contact and noncontact acts).

Different definitions of CSA and the number of screening questions used most likely contribute to most of the variability across studies. Definitions that use older age cutoffs, and include both contact and noncontact acts produce higher prevalence rates. In addition, surveys that use two or more screening questions for CSA typically result in higher prevalence rates compared to surveys using only a single question. For a thorough review of how different definitions and methods influence prevalence rates of CSA, see Finkelhor (1994). In this report, Finkelhor reviews the bulk of studies to date, and concludes that about 20 percent of North American women and about 5–10 percent of North American men report a history of CSA experiences that include both contact and noncontact acts. The 20 percent estimate for women is consistent with a recent nationally representative study of women in the USA that used multiple screening items for CSA and face-to-face interviews (Vogeltanz et al. 1999). Prevalence estimates from other countries, including Australia, the UK, The Netherlands, New Zealand, Spain, Sweden, and Switzerland, appear to be fairly consistent with the North American estimates, suggesting that CSA occurs at fairly consistent rates in European and English-speaking countries.

Some of these earlier general population studies measured possible consequences of CSA, but most varied significantly in the types of psychological problems assessed and the instruments used. For example, many studies used unstandardized questions about the occurrence of numerous psychological symptoms, others used standardized questionnaires and psychological symptom checklists, and a very few used structured clinical interviews that allowed the researcher to make a clinical diagnosis for several psychological disorders. Although results from these studies varied, the majority, like earlier clinical studies, reported significant relationships between adult women’s reports of experiencing CSA and their greater likelihood of experiencing current symptoms of substance abuse, depression, anxiety, sexual functioning problems, eating problems, and self-injurious behaviors. A large limitation of these studies, as with earlier clinical studies, was the relative lack of inclusion of men. Researchers preliminarily concluded that men with a history of CSA were also reporting elevated rates of various psychological problems.

In addition to reporting on the simple (bivariate) relationships between CSA and adult psychological problems in the general population, a few researchers looked at whether some characteristics of CSA might be more predictive of adult psychological problems. This preliminary data suggested that frequent and or severe abuse, and abuse by a biological parent have been modestly, but consistently linked to a greater likelihood of problems in adulthood.

By the 1990s, several comprehensive reviews of CSA research had been published, with most authors claiming that CSA was correlated with numerous psychological problems, symptoms, or disorders. However, the majority of studies on CSA did not use methodologies that could determine if CSA caused adult problems, and several researchers challenged this causal assumption. The basic argument was that many persons who report a history of CSA also report that their childhood family environments were pathologic, including such problems as conflicts with parent(s), physical or emotional abuse, lack of parental warmth or caring, living with only one biological parent, and parental psychopathology. Therefore, it may be these family environment factors are the causes of adult psychopathology as well as a risk factor for the occurrence of CSA. For an example of a prominent debate on this issue, see Nash et al. (1998). As a result of these challenges, it became incumbent upon CSA researchers to address this issue in future research.

To address cause-and-effect issues in epidemiological research, researchers must use either prospective designs or rigorous multivariate studies (see a description below on these methods). This final phase of research is complex and very costly, and only a few studies to date have been rigorous enough to allow for cause-and-effect interpretations. A summary of this work is described below.

2.3 Phase 3 Research: Studies Examining The Causal Status Of CSA On Adult Psychopathology

To date, only a few studies have been able to test adequately for a causal relationship between CSA and adult psychopathology. Although these studies vary in their definitions of CSA and measures of psychopathology, they are similar in three important ways. First, all the studies had large general population random samples of adults, or in one case, a nationally representative random sample of 10to 16-year-olds. Second, all of the studies used sophisticated methodologies that allowed for some level of causal interpretation. These methods were of two types: a prospective design, in which researchers collect multiple measures from individuals over time, therefore capturing a more accurate account of what happened before and after the occurrence of CSA; or cross- sectional multivariate designs, in which data about early family environment, the occurrence of CSA, and adult psychopathology are gathered at one point in time. Two twin studies using a cross-sectional multivariate design are also included here because the twin study provides unique information about possible genetic contributions to risk for CSA and highly shared environments. Although cross-sectional multivariate designs cannot definitively test for causal relationships, rigorous multivariate methodologies provide a high degree of confidence about causality. Finally, all of the studies used structured diagnostic interviews allowing for clinical diagnosis of psychological disorders. Although standardized questionnaires may also provide an important way of measuring levels of psychological symptoms or distress in the general population, a diagnosis provides a clear statement that the individuals being interviewed have experienced significant impairment in their lives. Diagnoses also provide information about lifetime occurrence of disorders, whereas symptom checklists typically assess only for current levels of functioning. The studies that meet the above criteria come from the USA, Australia, and New Zealand. In the first of two general population prospective studies, Fergusson and colleagues (1996) made yearly evaluations of a New Zealand sample of over 1,000 children from birth to age 18. At age 18, CSA before age 16 and diagnosable psychological disorders were measured. Results were that CSA significantly predicted major depression, anxiety disorder, conduct disorder, substance use disorder, and suicidal behaviors after controlling for prospectively measured family environment factors. The highest risk for having a psychological disorder was found among individuals reporting CSA intercourse experiences.

Boney-McCoy and Finkelhor (1996) used a prospective design in which they interviewed a nationally representative sample of children, aged 10–16, at two times, approximately 15 months apart. Results were that sexual assaults occurring to the children after the Time 1 interview predicted Time 2 diagnoses of major depression after controlling for previous lifetime occurrence of depression, the quality of the parent– child relationship, parental education, race, and whether the child lived with both parents. However, the strength of the sexual assault–major depression association was weaker after controlling for family environment factors.

Using a large random New Zealand community sample of women, Mullen and his colleagues (1993) reported that CSA was independently related to several diagnosed psychological disorders, after con- trolling for inadequate parenting, parental divorce, and early physical abuse. This study also found that the severity of abuse was the strongest predictor of later problems.

Finally, two twin studies also supported the in- dependent effects of CSA on adult psychological disorders, controlling for different aspects of family environment. Dinwiddie et al. (2000) conducted diagnostic interviews and measured CSA in 2,700 Australian twin pairs (male and female monozygotic and dizygotic pairs). A single question assessed for ‘forced’ CSA, and diagnoses were obtained for substance abuse, major depression, anxiety disorders, and conduct disorder. The only family environment factor measured was parental psychopathology. CSA significantly predicted all diagnoses in women and all but social phobia in men, after controlling for parental alcoholism and depression. The authors reported that when one twin reported CSA and the other twin did not (discordant for CSA), rates of disorders were not significantly different. However, further analyses revealed much higher rates of disorders among twins who were both abused (concordant), indicating that CSA may have specific effects on the development of disorders.

In the most recent and most sophisticated multivariate twin study to date, 1,411 adult female twins from the USA were given structured clinical interviews to determine lifetime diagnoses of major depression, generalized anxiety disorder, panic disorder, bulimia nervosa, alcohol dependence, drug dependence, and the presence of two or more of the disorders (comorbidity). CSA was measured using multiple screening questions to determine both contact and noncontact abuse. Several family environment factors were measured, but, uniquely, the researchers interviewed the respondents’ parents, and made clinical diagnoses of disorders and obtained parent ratings of various family environment factors. Results were that self-reported CSA of any kind was significantly associated with all disorders, except bulimia nervosa, after controlling for parental (or twin) reported family environment factors and history of parental psychopathology. In all disorders (including bulimia nervosa), intercourse CSA was more strongly related to psychological disorders than any other CSA form (genital, nongenital, or any CSA). As in the previous twin study, the cotwin control analyses indicated that there are specific effects of CSA on adult psychopathology, but that shared environmental factors clearly contribute to both risk of CSA and development of future disorders.

3. Conclusions

The studies reviewed used the most scientifically rigorous methods to date for testing the causal relation between CSA and adult psychopathology. The studies also had the benefit of all using the same type of measurement for adult psychopathology, a clinical interview that used psychiatric diagnostic criteria for determining the presence of a disorder. The studies support four main conclusions. (a) The statistical relationship between CSA and adult psychopathology remains significant after controlling for certain aspects of negative family environment, although the strength of the relationship attenuates from slightly to considerably, depending on the psychological disorder being predicted. (b) The reported strength or size of the independent relationships between CSA and risk for adult psychopathology were modest, indicating that (i) family environment serves as both a risk factor for CSA and a mediator for the effects of CSA on adult psychopathology; and (ii) many individuals who report a history of CSA do not develop adult problems. (c) More severe forms of CSA i.e., intercourse CSA, lead to a greater risk of developing psychological disorders. (d) Men were under-represented in these studies, but when studied, also had similar risks to women for developing psychological disorders as a consequence of CSA history.

4. Future Directions

Research on the prevalence, characteristics, and correlates of CSA has progressed enormously in the last two decades, and findings from each phase of research have informed the next. Despite this progress, there are still some core problems that should be corrected, including the need for standard definitions of CSA, more information about what measurement strategies result in the most accurate information about CSA, and the inclusion of more men in studies. Findings from current research indicate the need for future studies of CSA that assess for a wide range of family environment factors, because it is now certain that the effects of CSA on adult psychological problems are influenced by the familial context in which children live. There is no consensus, however, on which aspects of family environment most influence responses to traumatic events such as CSA, and this research is needed. Although there is some data suggesting that more severe forms of CSA lead to greater risk for adult problems, there is still much to be learned about how characteristics of the abuse may influence later problems, and how abuse characteristics may interact with family environment factors. For example, there is no information about how family environment factors may interact with CSA differently, depending on whether or not the abuser lives in the home with the child. Finally, more information is needed about what happens after CSA, including measurement of subsequent psychological problems, coping methods, and determining what factors seem to protect individuals from developing long-term psychological problems. In order to answer these questions, CSA researchers must continue to use prospective and multivariate cross-sectional studies, but there continues to be a great need for clinical and forensic studies that can inform the direction of more costly epidemiological studies.


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