The impact of child sexual abuse

A systematic meta-review of problems reported by survivors of child sexual abuse found that abuse is associated with many different problems across five primary domains: medical, psychological, sexual, repeated (self-)harm, and other problems. The reported outcomes have been found mostly independent of moderating variables such as frequency of the abuse, relationship to perpetrator and type of control group (Nagtegaal & Boonmann, 2021).

In a review of the impacts of institutional child sexual abuse, Blakemore and colleagues (2017) likened institutional abuse to intra-familial sexual abuse, noting similarities in terms of its chronicity, severity and relational aspects, and described impacts as “pervasive, numerous and connected”. These authors noted negative impacts across psychological (e.g. post-traumatic stress symptomology, depression, anxiety), physical (e.g. self-reported quality of health, sleep problems), social (e.g. relationship, parenting and sexual difficulties), educational (e.g. school completion, engagement) and economic (e.g. obtaining and maintaining employment) domains.

Child sexual abuse is associated with a range of detrimental and often inter-related outcomes. While child sexual abuse has been shown to be associated with individually increased risks for public mental health service contacts, offending, subsequent victimisation and deaths by suicide or drug overdose, a study by Papalia and colleagues (2017) has shown that these adverse outcomes also tend to co-occur among survivors. For example, this research showed a three-way interaction between public mental health service contact, criminal history and subsequent victimisation – notably, the presence of a psychiatric history increased the likelihood of co-occurring offending and further victimisation among survivors of child sexual abuse (Papalia, Luebbers, Ogloff, Cutajar & Mullen, 2017).

An umbrella review synthesising meta-analytical findings on the outcomes of child sexual abuse found evidence for associations between sexual abuse and a wide range of psychiatric diagnoses, as well as negative psychosocial and physical health outcomes in adulthood, with particularly strong evidence existing for links between child sexual abuse and later post-traumatic stress disorder, schizophrenia, and substance misuse (Hailes, Yu, Danese & Fazel, 2019).

Many reviews have described the various long term impacts of child sexual assault, while indicating that child sexual assault does not reliably predict any one condition or set of difficulties (Barnes & Josefowitz, 2014). In this way, the experience of child sexual abuse has been described as a non-specific risk factor for a multitude of adverse outcomes (Cashmore & Shackel, 2014).

Barnes and Josefowitz (2014) listed a number of outcomes that have been associated with experience of child sexual assault, include psychological difficulties such as depression, anxiety, sleep disorders, personality disorders and psychotic disorders, behavioural problems such as substance abuse, self-harm, eating disorders, conduct disorders and antisocial behaviour, as well as relationship difficulties, poorer physical health, and poorer educational and occupational achievement.

A study of over 1,000 children with both objective court-documented evidence of maltreatment and subjective reports of childhood maltreatment made as adults, found that, even for severe cases of maltreatment identified in court records, psychopathology was less likely when these children, as adults, did not also make subjective reports of maltreatment. Risk of psychopathology increased, however, when children made subjective reports of maltreatment as adults. This research suggests that the impact of childhood sexual assault emerges as a result of subjective experiences, rather than objective experiences of childhood maltreatment (Danese & Spatz Widom, 2020).

Research has identified several key factors that are predictive of increased negative impact into adulthood, including a child’s younger age at first experience, greater number of sexual assault episodes, longer duration of the abuse, the presence of coercion, force or threats, more invasive sexual contact, more than one perpetrator, parental mental illness, criminal activity and substance use, and perpetration by a father or father figure (Barnes & Josefowitz, 2014; Martin & Silverstone, 2013). Social support, meanwhile, has been shown to mediate the effect of trauma and reduce the likelihood of negative outcomes resulting from experiences of child sexual abuse (Charuvastra & Cloitre, 2008).

The impacts of child sexual abuse are thought to occur across at least three stages, with the child’s initial reaction to their victimisation, followed by their accommodation to ongoing abuse (if relevant), and the longer term impact on adolescent and adult functioning (Briere & Elliott, 1994).

Short-term impacts

Children exposed to complex trauma may experience impacts and show impairment across seven primary domains – attachment (e.g. development of insecure attachment patterns), biology (e.g. failure to develop brain capacities necessary for modulating emotions), affect regulation (e.g. inability to discriminate among and label affective states), dissociation (e.g. detachment from awareness of emotions and self), behavioural regulation (e.g. under-controlled and over-controlled behaviour patterns), cognition (e.g. lower grades and poorer academic achievement), and self-concept (e.g. self-perception as defective, helpless, deficient) (Cook et al., 2005).

Data from children involved in a US-based panel study found that youth who had experienced sexual abuse had lower grades in school, were more likely to drop out, and had lower levels of education than those who had not experienced sexual abuse. Child sexual abuse was found to have an impact on positive future orientation, which in turn impacted on academic outcomes for these children (Ochoa & Constantin, 2023).

Australian linkage projects have found that children who have contact with the child protection system are more likely than other children to have contact with the juvenile justice system and homelessness services, and to have lower literacy and numeracy achievement (AIHW 2015, 2016).

A study examining behavioural problems over childhood and adolescence in sexually abused versus maltreated, but non-sexually abused children, showed that those with a history of sexual abuse had significantly greater internalising and externalising behaviour problems over time when compared to those without sexual abuse histories (Lewis, McElroy, Harlaar, & Runyan, 2016).

In the short term, Kendall-Tackett and colleagues’ (1993) review of 45 studies showed that children who have experienced child sexual abuse have more symptoms, including for example, behaviour problems, poor self-esteem, and sexualised behaviours, than those who have not experienced sexual abuse.

A recent longitudinal matched-cohort study has shown that sexual abuse is associated with a 1.27 increased risk of infectious disease diagnoses in children and adolescents (Dargan et al., 2019).

A study of 14-18 year old adolescents in Canada found that while overall, boys had higher levels of self-esteem than girls, the opposite was true among victims of child sexual assault: boy victims had lower self-esteem than girl victims. Among victims of CSA, boys reported lower levels of self-esteem than girls, which in turn was associated with an increased risk of displaying delinquent behaviours (Gauthier-Duchesne, Hebert & Blais, 2021).

Complex trauma

The experience of sexual abuse during childhood is a key antecedent of complex trauma symptoms. Research has shown that the symptoms of complex trauma most often result from prolonged exposure to multiple forms of interpersonal trauma (including sexual abuse), typically during childhood, by caregivers who are expected to provide a safe, predictable, and secure environment (Courtois & Ford, 2013). Sexual abuse perpetrated by a caregiver is associated with particularly severe complex trauma symptoms into adulthood (Kluft, 2011).

The International Society for Traumatic Stress Studies (Cloitre et al., 2012) task force’s definition of complex trauma includes the core symptoms of posttraumatic stress disorder alongside disruptions in self-regulatory capacities across five domains: (a) emotion regulation, (b) self/relational capacities, (c) alterations in attention and consciousness, (d) belief systems, and (e) somatic symptoms and/or medical problems.

Complex trauma is distinguished by its pervasive effects; it is not only a range of functions which are negatively impacted but also development and functioning of the self (Courtois & Ford, 2013). In contrast to “single incident” trauma (which relates to an unexpected and “out of the blue” event), complex trauma is cumulative and repetitive. When this occurs at critical developmental periods, it compromises psychobiological, social and emotional development (Courtois & Ford, 2013).

Intergenerational trauma and victimisation

Multiple studies have shown that mothers who report childhood sexual victimisation are more likely to have a child who has also experienced sexual abuse (e.g., Avery, Hutchinson, & Whitaker, 2002; Zuravin, McMillen, DePanfilis, & Risley-Curtis, 1996).

The relationship between mothers’ experience of childhood abuse and their children’s’ subsequent victimisation has been interpreted as being due to the negative consequences of child sexual abuse, such as trauma symptoms, early pregnancy, and substance use, that create a harmful environment for the child and increase their vulnerability to abuse (Noll, Trickett, Harris, & Putnam, 2009; Serbin & Karp, 2004).

A comparison of mother and (young adult) child pairs examined the difference between intergenerational cycle maintainers, breakers, initiators, and a control group. This research supported previous work in revealing a higher risk of child sexual abuse in pairs where the mother experienced child sexual abuse. Additionally, this research found that compared to cycle initiators, maintainers reported greater psychological distress and lower ratings of parent-child attachment. Mothers in cycle maintaining pairs also were exposed to more acts of domestic violence than were those in cycle breaking pairs (Marshall, Fernet, & Langevin, 2022).

Links to mental health and suicide

The Australian Child Maltreatment Study (ACMS), the first nationally representative study of child maltreatment rates, found that Australians who experienced child sexual abuse are 2.7 times more likely to have self-harmed, and 2.3 times more likely to have attempted suicide, in the prior 12 months (Lawrence, Hunt, Mathews, et al., 2023).

The ACMS also found that Australians who had experienced child sexual abuse are 1.95 times more likely to develop post-traumatic stress disorder, 1.65 times more likely to develop generalised anxiety disorder, 2.12 times more likely to develop a severe alcohol use disorder, and 1.66 times more likely to develop major depressive disorder than the general Australian population (Scott, Malacova, Mathews, et al., 2023).

A study using data from the WHO World Mental Health surveys (conducted across 21 countries with more than 51,000 adult participants) examined the prevalence and associations of retrospectively reported childhood adversities (ACEs) with first onset of a wide variety of mental disorders across the lifespan. Findings show that eradication of childhood adversities would lead to a 22.9% reduction in mood disorders, 31% reduction in anxiety disorders, 41.6% reduction in behaviour disorders, 27.5% reduction in substance disorders and 29.8% reduction in all disorders. In sum, ACEs were found to account for 30% of all mental disorders worldwide (Kessler et al., 2010).

Examination of three conditions directly linked to child abuse and neglect: anxiety disorders, depressive disorders, and suicide and self-inflicted injuries, were estimated to have been responsible for 0.5% of all deaths and 2.2% of the burden of disease and injury in 2015 (AIHW, 2019). More specifically, it was estimated that there would have been 26% less suicide and self-inflicted injuries, 20% less depressive disorders and 27% less anxiety disorders in 2015 if no one in Australia had ever experienced child abuse and neglect during childhood (AIHW, 2019).

A study utilising data from a German-wide sexual abuse helpline found that callers with experiences of female perpetrated and male perpetrated sexual abuse experienced similar severe and long-term mental health consequences from the abuse. While the severity of outcomes was similar, specific mental disorders differed, with callers reporting experiences of female perpetrated sexual abuse more likely to report suicidality, self-injury behaviour, personality disorders, dissociative identity disorders, and alcohol or drug addiction, and callers reporting experiences of male perpetrated sexual abuse more likely to report post-traumatic stress disorder, affective disorders, and anxiety disorders (Gerke, Gfrorer, Mattstedt, Hoffmann, Fegert & Rassenhofer, 2023).

Men’s experience of child sexual abuse has been shown to be positively associated with depressive and somatic symptoms as well as hostility into middle and late adulthood (Easton & Kong, 2017).

A study of child sexual abuse, its co-occurrence with other forms of maltreatment, and mental health outcomes among males has shown that having a history of child sexual abuse only, and of child sexual abuse co-occurring with other types of maltreatment, was associated with higher odds for many mental disorders and suicide attempts compared to having a history of child maltreatment without sexual abuse (Turner, Taillieu, Cheung, & Afifi, 2017).

A New Zealand birth cohort study found that sexual abuse prior to age 16 was associated with a range of adverse outcomes at age 30, including depression, anxiety, PTSD symptoms, and reduced self-esteem and life satisfaction (Fergusson, McLeod & Horwood, 2013). These negative outcomes were also found to increase alongside the increasing severity of abuse experienced (Fergusson et al., 2013).

Rates of suicide are significantly higher among victims of child sexual abuse than comparison groups. One study found sexual abuse victims were 18 times more likely to commit suicide than those in the general population (male abuse victims 14 times more likely and female victims 40 times more likely) (Cutajar, Mullen, Ogloff, Thomas, Wells, & Spataro, 2010).

Links to physical health

A survey study with a representative sample of Canadian adults showed that experience of all types of child abuse, including child sexual abuse, was associated with having a physical health condition in adulthood. Child sexual abuse was also associated with an increased risk of obesity in adulthood (Afifi, MacMillan, Boyle, et al., 2016).

One in 10 respondents to a 2015 Texas Behavioral Risk Factor Surveillance System survey reported experiencing childhood sexual abuse. Individuals who reported child sexual abuse were more likely to report their general health as poor, and to report 14 or more physical unhealthy days, 14 or more mental unhealthy days, and 14 or more activity limitation days in a month. Health-related quality of life outcomes were poorer among those who had experienced more severe forms of child sexual abuse, including penetrative abuse (Downing, Akinlotan, & Thornhill, 2021).

A study of the prevalence of child sexual abuse and its impact on the health of adults in Saudi Arabia found that participants who reported child sexual abuse had 1.7, 2,2 and 3.8 times the odds of diabetes, coronary heart disease and obesity diagnosis respectively compared to participants with no history of child sexual abuse (Almuneef, 2021).

Women with a history of sexual abuse were more likely to use mental health services, pharmacy services, primary care services and speciality care (Bonomi, 2008).

Compared to those with no history of abuse, annual health care costs were 16% higher for women who reported childhood sexual abuse (Bonomi, 2008).

Links to drug and alcohol misuse

The Australian Child Maltreatment Study found that Australians who experienced child sexual abuse are 2 times more likely to be cannabis dependent (Lawrence, et al., 2023).

Forty-seven articles included in a recent systematic review, covering a range of topics related to child sexual abuse and later substance use issues, found a clearly supported link between child sexual abuse and substance use issues later in life (Fletcher, 2020).

Experience of child sexual abuse has been shown to be associated with heavy drinking, hazardous drinking, and the use of marijuana and other illicit drugs – these associations have also been shown to be only marginally attenuated when controlling for depression and self-reported emotional and mental health (Tonmyr & Shields, 2017).

A New Zealand birth cohort study found that sexual abuse prior to age 16 was associated with a range of adverse outcomes at age 30, including alcohol and drug dependence, as well as depression, anxiety, PTSD symptoms, and reduced self-esteem and life satisfaction (Fergusson, McLeod & Horwood, 2013).

Rates of accidental fatal overdoses are significantly higher for victims of child sexual abuse than comparison groups. Sexual abuse victims were 49 times more likely to die as a result of an accidental overdose than those in the general population (male abuse victims 38 times more likely and female victims 88 times more likely) (Cutajar et al., 2010).

Links to crime

A prospective study examining the effects of child sexual abuse on life-course offending found that victims of sexual abuse were more at risk of offending (non-sexual offences) than were controls, but that so too were their siblings. Only female victims were more likely to offend than their siblings. The authors concluded that family and environmental factors were most important in explaining life-course offending among male sexual abuse victims, while these factors were not sufficient to explain the link between child sexual abuse and offending among females (de Jong & Dennison, 2017).

A large-scale Australian study, which followed-up 2,759 substantiated cases of child sexual abuse over 31 years alongside a large comparison group, showed that child sexual abuse victims were significantly more likely to have a recorded offence (24%) than those who were not sexually abused as children (6%). The average number of charges among child sexual abuse victims was also significantly higher than among those in the comparison group (Ogloff, Cutajar, Mann & Mullen, 2012).

A later examination of this same longitudinal data-set of 2,759 substantiated CSA cases found that CSA victims were more likely to engage in all types of criminal behaviours including violent, sexual and other offending, and that there were stronger associations between CSA and general and violent offending among females, and between CSA and sexual offending among males. This study also showed that sexual and violent revictimisation subsequent to the index sexual abuse was strongly associated with an increased likelihood of most forms of offending behaviour, for both males and females (Papalia, Ogloff, Cutajar, & Mullen, 2018).

A study examining the relationship between Adverse Childhood Experiences and criminal behaviours in young adults living in 10 countries found that child sexual abuse among females was the strongest predictor of criminal behaviour in the study. The link was weaker among males than females, which the authors suggested may be explained by the fact that females are more likely than male victims to have experienced more severe and chronic sexual abuse and have a greater likelihood of self-blame than males (Basto-Pereira, Gouveia-Pereira, Pereira et al., 2022).

Revictimisation

In addition to socio-emotional and mental health sequelae, numerous studies have highlighted that child sexual abuse victims are vulnerable to later sexual re-victimisation (Lalor & McElvaney, 2010).

In the Australian Longitudinal Study on Women’s Health, women aged 24 to 30 in 2019 who had experienced childhood sexual violence were twice as likely to have experienced recent sexual violence, 59% more likely to have experienced recent domestic violence, and approximately 60% more likely to likely to have experienced recent physical violence, than were women of the same age who did not report sexual violence in childhood (Townsend et al., 2022).

A prospective-longitudinal study of 2,759 Australian children (<17 years old) who experienced contact sexual abuse, followed these children and a matched comparison group to age 35 years on average, and found that child sexual abuse victims experienced significantly higher rates of revictimization, with marked increases in odds for interpersonal revictimization, including sexual and physical assault, threats of violence, and stalking (Papalia, Mann & Ogloff, 2020). Widom, Czaja and Dutton (2008) report the findings of a prospective study of children physically and sexually abused between 1967 and 1971, and a comparison group of non-abused children matched for sex, age race and socioeconomic status. Both groups were followed up and interviewed between 2000 and 2002 (at a mean age of 39.5 years). Those who experienced abuse/neglect in childhood had significantly higher rates of sexual assault/abuse in adulthood (47.7% vs. 28.6%).

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